According to the Canadian Rheumatology association guidelines:

1. Methotrexate can be continued in the preoperative period in patients with rheumatoid arthritis undergoing elective orthopaedic surgery.

2. Biologic medications should be held before surgical procedure according to the parmacokinetic properties of the medication and nature of the surgery. They can be restarted if there are no signs of infection and the wound is healing properly.


According to the European League Against Rheumatism (EULAR) textbook:

1. Sulfasalazine can be stopped 2 days before surgery. It can be continued in general in patients with anticipated quick recovery.

2. Prednisone in a dose of < 7.5 mg/day is acceptable without impairing wound healing.

3. Hydroxychloroguine can be continued in preoperative period.

4. Interruption is required for the biologic agents before elective surgery:

  • infliximab 4-7 weeks (half life 10 days)
  • etanercept 2 weeks (half life 3-4 days)
  • 8-10 weeks interruption for adalimumab, certolizumab, golimumab, tocilizumab, abatacept
  • rituximab 20-24 weeks (half life 19-22 days)

5. Leflunomide has a very long half life, so stopping it does not seem to be adequate.

6. Methotrexate is safe to continue during perioperative period.