Perioperative Management of Tofacitinib

Preoperative Considerations

The American College of Rheumatology recommends withholding tofacitinib for at least 7 days prior to elective surgery in patients with rheumatoid arthritis, spondyloarthropathies, psoriatic arthritis, or juvenile idiopathic arthritis, due to increased risk of serious infection (incidence rate 2.91, 95% CI 2.27-3.74) and overall infection risk (RR 5.7, 95% CI 1.8-18.1) 1, 2, 3, 4
Despite tofacitinib's short serum half-life, the duration of immunosuppression after discontinuation is not well understood, though indirect translational data suggest host defense returns to normal at 7 days 2, 3

The American College of Rheumatology recommends resuming tofacitinib only after confirming adequate wound healing (generally requiring a minimum of 14 days postoperatively) and verifying absence of both surgical site infection and systemic infection 7, 1
Clinical judgment should guide the decision to restart, with careful assessment of wound integrity, suture/staple removal status, and any signs of infection 7

Very limited data exist for perioperative tofacitinib safety in inflammatory bowel disease patients, but available studies suggest an increased risk of venous thromboembolic events (VTE) 5, 6
Prolonged VTE prophylaxis should be considered in IBD patients exposed to tofacitinib perioperatively, potentially extending beyond hospital discharge 5, 6

The FDA has issued a black box warning for all JAK inhibitors, including tofacitinib, regarding increased infection risk, including serious infections 8
Tofacitinib demonstrates dose-dependent infection risk, and patients with acute severe ulcerative colitis receiving tofacitinib face additional thrombosis risk beyond baseline disease-related risk 8

For elective orthopedic surgery, plan surgery at least 7 days after last tofacitinib dose, and withhold tofacitinib for a minimum of 7 days before elective surgery in patients with rheumatic diseases undergoing total hip or knee arthroplasty 1, 2, 4
For IBD-related surgery, withhold tofacitinib and implement enhanced VTE prophylaxis protocols 5, 6