Perioperative management of antirheumatic medication in rheumatoid hand surgery

1. Perioperative antirheumatic medication recommendations for hip and knee arthroplasty can be applied to elective hand surgery without considering the procedure or the patient’s individual risks.

False

Perioperative recommendations developed for major joint arthroplasty do not automatically apply to every hand procedure. Decisions should consider the procedure, infection risk and the risk of a disease flare. Hand-surgery data on biologic drugs did not show a significant increase in infection or wound-healing failure with continuation, but a modest increase in infection risk could not be excluded.

• Goodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, et al.. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Rheumatol. 2022;74(9):1464-1473. PMID 35722708
• Cathey JM, Carrigan PJ, Zhang J, Klifto KM. Perioperative Biologic Disease-Modifying Antirheumatic Drugs, Risks of Infections, and Wound Complications in Patients With Rheumatoid Arthritis Undergoing Elective Hand Surgery. J Hand Surg Am. 2026;51(7):751.e1-751.e10. PMID 41973898

2. Pooled randomised data show that withholding conventional synthetic disease-modifying antirheumatic drugs (DMARDs) around elective orthopaedic surgery reduces postoperative infections.

False

A 2026 Cochrane review found three trials (306 participants with rheumatoid arthritis) in which methotrexate or leflunomide was stopped around elective orthopaedic surgery. Low-certainty evidence showed little or no effect on postoperative infection (3% in each group at 12 months) and a possible increase in flares. In Grennan and colleagues' randomised study, continuing methotrexate did not increase infections or surgical complications within one year.

• Ponkilainen V, Karjalainen TV, Kuitunen I, Uimonen M, Johnston RV, Saarinen A, et al.. Perioperative use of disease-modifying anti-rheumatic drugs (DMARDs) in people with inflammatory arthritis. Cochrane Database Syst Rev. 2026;5(5):CD015096. PMID 42159164
• Grennan DM, Gray J, Loudon J, Fear S. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis. 2001;60(3):214-7. PMID 11171680

3. In a large database study of elective hand surgery in rheumatoid arthritis, continuing biologic DMARDs perioperatively was not associated with a significant increase in surgical site infection or wound-healing failure.

True

Cathey and colleagues compared 881 propensity-matched pairs who continued or discontinued biologic DMARDs and found similar 90-day risks of surgical site infection (2.0% against 1.5%) and wound-healing failure (1.4% in both), although a modest increase in infection risk could not be excluded. A 2015 meta-analysis of orthopaedic surgery, mostly with tumour necrosis factor inhibitors, found a slight increase in surgical site infection with biologics but no increase in delayed wound healing.

• Cathey JM, Carrigan PJ, Zhang J, Klifto KM. Perioperative Biologic Disease-Modifying Antirheumatic Drugs, Risks of Infections, and Wound Complications in Patients With Rheumatoid Arthritis Undergoing Elective Hand Surgery. J Hand Surg Am. 2026;51(7):751.e1-751.e10. PMID 41973898
• Ito H, Kojima M, Nishida K, Matsushita I, Kojima T, Nakayama T, et al.. Postoperative complications in patients with rheumatoid arthritis using a biological agent - A systematic review and meta-analysis. Mod Rheumatol. 2015;25(5):672-8. PMID 25671400

4. In a retrospective study of patients with rheumatoid arthritis taking Janus kinase inhibitors, a longer perioperative withholding period was associated with more postoperative flares.

True

Bekki and colleagues matched 62 patients taking Janus kinase (JAK) inhibitors with 62 taking biologic DMARDs; postoperative flares were more frequent with JAK inhibitors (29% against 12.1%). Within the JAK inhibitor group, withholding for 11 days or more was associated with flares, whereas delayed wound healing and surgical site infection were not associated with the length of withholding. The study is retrospective and small.

• Bekki H, Hashiguchi T, Kawamura S, Kondo M, Tsushima H, Sakuraba K, et al.. Complications after orthopaedic surgeries in patients with rheumatoid arthritis treated with Janus kinase inhibitors: A retrospective observational study. Mod Rheumatol. 2024;34(5):954-959. PMID 38123463

5. In patients at risk of glucocorticoid-induced adrenal insufficiency, continuing the usual daily corticosteroid dose provides sufficient cover for every surgical procedure.

False

Current guidelines recommend stress-dose coverage in patients with current or recent glucocorticoid exposure when adrenal insufficiency has not been excluded. The dose and route depend on surgical stress, anaesthesia and oral intake; general or regional anaesthesia usually requires parenteral coverage. An existing glucocorticoid dose that already meets the stress requirement may be sufficient. These recommendations are based on clinical guidance rather than definitive randomised comparisons.

• Beuschlein F, Else T, Bancos I, Hahner S, Hamidi O, van Hulsteijn L, et al.. European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and Therapy of Glucocorticoid-induced Adrenal Insufficiency. J Clin Endocrinol Metab. 2024;109(7):1657-1683. PMID 38724043