Perioperative Management of Biologics and Conventional DMARDs for Knee Surgery

Medication Management

The American College of Rheumatology recommends continuing methotrexate through surgery without interruption, as it reduces infection risk (RR 0.39) and disease flare risk (RR 0.06) 1, 2, 3, 4
The American College of Rheumatology recommends withholding tocilizumab prior to surgery and timing the surgery to occur when the next dose would be due, to minimize infection risk and disease activity 1, 2, 3, 4
For patients on intravenous tocilizumab, schedule surgery 4 weeks after the last dose, and for those on subcutaneous tocilizumab, schedule surgery at the corresponding interval after the last dose 2

The 2022 ACR/AAHKS guidelines recommend continuing conventional DMARDs like methotrexate due to low-to-moderate quality evidence showing decreased infection risk and significant reduction in disease flares when MTX is continued 1, 3, 4
Biologic agents, including tocilizumab, increase serious infection risk, and the guideline panel determined that the infection risk outweighs the flare risk during the brief perioperative period 2, 3, 4

Resume tocilizumab approximately 14 days after surgery once the wound shows clear evidence of healing, all sutures or staples have been removed, and there is no evidence of surgical site infection or other active infections 1, 2, 4, 5

If a patient has a history of severe or recurrent infections, consider holding methotrexate as well, despite the general recommendation to continue it 1, 3
Patients on prednisone or other steroids should continue their current daily dose rather than receiving stress-dose steroids 1, 6
Monitor for disease flare symptoms during the tocilizumab interruption period, though the risk is low with continued methotrexate 1, 3