Methotrexate Continuation During Minor Surgery for Rheumatoid Arthritis Patients

Evidence for Continuing Methotrexate During Surgery

The 2022 American College of Rheumatology (ACR) conditionally recommends continuing the usual dosing of methotrexate through surgery for patients with rheumatoid arthritis undergoing total hip or knee arthroplasty 1
The American College of Rheumatology recommends that continuing DMARDs like methotrexate is associated with a decreased risk of infections (relative risk 0.39, 95% CI 0.17-0.91) based on low to moderate quality evidence 3
The British Association of Dermatologists' guidelines support that methotrexate can be continued during the perioperative period when it is controlling an individual's disease 4, 5
Multiple randomized controlled trials have demonstrated that continuing methotrexate during orthopedic surgery does not increase infection risk and actually reduces the frequency of rheumatoid arthritis flares postoperatively 6, 7

Patients who continue methotrexate during surgery experience significantly fewer rheumatoid arthritis flares compared to those who discontinue the medication 7
Continuing methotrexate helps maintain disease control, which is crucial for optimal recovery and rehabilitation after surgery 6

For patients with significant comorbidities that increase infection risk, the decision to continue methotrexate should be made on a case-by-case basis 5
The American College of Rheumatology recommends that biologic agents should be withheld prior to surgery according to their dosing cycle 1, 3
Patients on JAK inhibitors should withhold these medications for at least 3 days prior to surgery 1
If methotrexate is withheld for any reason, it should be restarted once the wound shows evidence of healing, typically around 14 days post-surgery 1

For minor surgery in RA patients, the American College of Rheumatology recommends continuing the regular methotrexate dosing schedule without interruption 1, 4
The British Association of Dermatologists recommends maintaining the patient's usual folic acid supplementation (at least 5 mg weekly) 8
For patients on multiple immunosuppressive medications, consider the cumulative immunosuppressive effect when making decisions about perioperative medication management 4