Hydroxychloroquine Management During Elective Surgery

Primary Recommendation

The 2022 American College of Rheumatology / American Association of Hip and Knee Surgeons guideline conditionally recommends continuing the usual dose of hydroxychloroquine through elective surgery for patients with rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis, and all forms of systemic lupus erythematosus (both severe and non‑severe). 1, 2

The recommendation applies to all types of elective surgery, with the strongest supporting evidence derived from orthopedic procedures. 1, 2

Hydroxychloroquine monotherapy – Continue the usual daily dose (generally 200–400 mg) on the day of surgery; no dose adjustment or timing modification is required. 1, 2
Hydroxychloroquine + biologic agents – Continue hydroxychloroquine; withhold the biologic and schedule surgery when the next biologic dose would have been due. 1, 2
Severe SLE on multiple immunosuppressants – Continue hydroxychloroquine and continue other immunosuppressants (e.g., mycophenolate, azathioprine, tacrolimus) when disease is severe. 1, 2
Non‑severe SLE on multiple immunosuppressants – Continue hydroxychloroquine; withhold other immunosuppressants (mycophenolate, azathioprine, tacrolimus) for approximately one week before surgery. 1, 2

Do not routinely hold hydroxychloroquine “to be safe”; doing so increases postoperative infection and disease‑flare risk without clear benefit. 1, 2
Do not confuse hydroxychloroquine management with biologic management; the two have opposite peri‑operative recommendations. 1, 2
Do not delay restarting hydroxychloroquine after surgery if it was held; resume once wound healing is evident (typically around 14 days). 1, 2

The recommendation to continue hydroxychloroquine is based on low‑to‑moderate quality evidence, resulting in a conditional (rather than strong) recommendation. The balance of benefits (reduced infection and flare risk) outweighs theoretical cardiac risks in patients without severe contraindications. 1, 2

The American College of Rheumatology recommends continuing hydroxychloroquine during elective orthopedic surgery, based on low to moderate quality evidence showing a reduction in infection risk and disease flare-ups 3, 4, 5, 6

The American College of Rheumatology conditionally recommends continuing the usual dose of hydroxychloroquine during elective hip or knee replacement surgery, with evidence demonstrating a reduced risk of infection (RR 0.39, 95% CI 0.17-0.91) and significant decrease in postoperative disease flare-ups (RR 0.06, 95% CI 0.0-1.10) 3, 4, 6
Hydroxychloroquine, methotrexate, leflunomide, and sulfasalazine should be continued during surgery, whereas biologic agents should be suspended before surgery and the operation scheduled at the end of the dosing cycle 3, 4, 5, 6, 7

For patients with non-severe systemic lupus erythematosus (SLE), hydroxychloroquine should be continued during surgery, while for those with severe SLE, it should definitely be continued 3, 4, 5
Other immunosuppressants in SLE (mycophenolate, azathioprine, tacrolimus) should be suspended 1 week before surgery if the SLE is not severe 3, 6

For elective orthopedic surgery: if the patient is taking hydroxychloroquine for rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis, or SLE, it should be continued during surgery 3, 4, 5, 6
If the patient is also taking biologics, the biologics should be suspended and hydroxychloroquine continued 3, 4, 7