Peri‑operative Management of Upadacitinib in Geriatric Patients

Pre‑operative Withholding

Withhold upadacitinib for at least 3 days before any surgical procedure. This short interval replaces the earlier 7‑day recommendation for tofacitinib and is based on trial data showing rapid loss of disease control after JAK‑inhibitor interruption, indicating a quick reversal of immunosuppression【@1】.
The 3‑day withholding applies to patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or juvenile idiopathic arthritis who are undergoing total hip or knee arthroplasty【@1】.

Restart upadacitinib only after clear evidence of wound healing, complete removal of all sutures or staples, absence of significant swelling, erythema, or drainage, and no clinical evidence of infection at the surgical site or elsewhere【@1】.

The typical restart window is around 14 days post‑surgery, reflecting the usual period required for normal wound closure【@1】.
This timing recommendation is conditional and based on low‑quality evidence; clinicians should individualise the decision according to patient‑specific factors【@1】.

Extend the withholding period in older patients who have any of the following risk factors:
- History of severe or recurrent infections【@5】.
- Prior prosthetic joint infection【@5】.
- Compromised wound‑healing capacity (e.g., poor tissue perfusion)【@7】.
Trial data demonstrate that disease activity rises rapidly after JAK‑inhibitor interruption, underscoring the need for careful timing in this population【@5】.

The current guidance focuses on infection risk and does not incorporate cardiovascular or venous thrombo‑embolism considerations【@3】.

Prolong withholding beyond 14 days if any of the following occur:
- Wound‑healing complications (e.g., dehiscence)【@7】.
- Emergence of signs of infection (surgical or distant)【@7】.
- Persistent wound drainage【@7】.
- Ongoing inflammatory signs such as swelling or erythema【@3】.

For patients with a history of severe infections or prosthetic joint infection, clinicians and patients may elect a longer medication‑free interval after surgery【@8】.
Because the recommendation is conditional, it emphasizes the importance of shared decision‑making between the healthcare team and the patient【@1】.