Should I stop taking my immunosuppressants before undergoing joint replacement and if so for what period?

Should I stop taking my immunosuppressants before undergoing joint replacement and if so for what period?

Given that many autoimmune conditions degrade joints, this is a situation that many patients face. Unfortunately, there is no clear consensus among clinical practice relating to perioperative use of immunosuppressants.  Each patient should go over the options with both their surgeon and rheumatologist. The following are aspects that patients and doctors need to consider before reaching a decision.

Cessation of autoimmune medications means a risk of disease flare. Continuing to take medications could lead to impaired wound healing and put patients at a greater risk of infection. These potential problems may be interpreted differently based on professional medical opinion, patient history, and type of medication.

Methotrexate is one of the most common first line autoimmune medications prescribed. For patients on this medication, evidence supports the idea that this drug is safe to continue preoperatively. Researchers have found no significant difference in both early complication rates and in complications up to one year after surgery between patients that continue or stop methotrexate. Systematic reviews have concluded that continued methotrexate use appears safe pre and postoperatively and was associated with a reduced risk of a flares. It is important to note that patients with comorbidities (such as age, liver disease or if the surgery is treatment for a major infection) or those using extremely high doses of methotrexate may require additional scrutiny before a decision can be made.

TNF-α antagonists are another class of drugs commonly used to treat autoimmune conditions. Unlike methotrexate, the data relating to use of these drugs when undergoing surgery does not offer clear answers, with different studies providing conflicting results. A retrospective study looking at RA patients that received surgical orthopedic procedures found no significant differences in wound healing between those who did suspend drug use and those who did not. There were, however, more cases of surgical wound sites re-opening in patients that continued TNF- α antagonist use. Other systematic reviews and studies found that patients who were taking TNF- α antagonists (compared to those on other disease-modifying antirheumatic drugs) experienced higher rates of skin and soft tissue infection rates, but there was no difference in the rate of serious infections. It does appear that the risk of infection tends to be greatest at the start of TNF- α antagonist therapy and patients with established disease and treatment are at greater risk of a flare if therapy is halted for a period. The American College of Rheumatology and British Society of Rheumatology recommend stopping TNF- α antagonists for one dosing cycle before major surgery (for minor surgeries it is generally considered safe to continue use). Restarting therapy is usually considered safe 10-14 days after surgery or after wound healing is deemed satisfactory by the treating surgeon.

The newest class of drugs used to treat autoimmune conditions, biologics (such as Rituximab), have a lower risk for bacterial infections than TNF-α antagonists. Biologics have been shown to be safe in patients even if there is a history of recurrent bacterial infections.

A drug recently in the news in relation to the COVID-19 pandemic, hydroxychloroquine (or Plaquenil), is considered to be safe during the preoperative period. It is generally recommended that patients continue this medication without stopping even when undergoing surgery.

At the end of the day, the decision will depend on both the individual patient profile (blood counts, previous surgical complications etc.) and the specific drug they are taking as well as the preferences of their treating doctors.

Article Author
Arthritis National Research Foundation

The Arthritis National Research Foundation's mission is to provide initial research funding to brilliant, investigative scientists with new ideas to cure arthritis and related autoimmune diseases. Writing articles about the patients affected and the science being done to find a cure shows why we need to come together to #CureArthritis!

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