Patients with rheumatoid arthritis, psoriatic arthritis, lupus, and related conditions often take disease-modifying antirheumatic drugs (DMARDs) or biologic medications. These powerful drugs affect the immune system, which raises questions about infection risk and wound healing around surgery. This guide summarizes current guidance from the American College of Rheumatology (ACR) to help patients have informed conversations with their surgical and rheumatology teams.
What Are DMARDs and Biologics?
Conventional DMARDs are oral medications that modify the immune system to slow disease progression. Common examples include methotrexate, hydroxychloroquine (Plaquenil), sulfasalazine, and leflunomide (Arava).
Biologic DMARDs are injectable or infused medications that target specific proteins in the immune system. Common examples include adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade), rituximab (Rituxan), and abatacept (Orencia).
JAK inhibitors are oral medications that block specific enzymes involved in inflammation. Examples include tofacitinib (Xeljanz), baricitinib (Olumiant), and upadacitinib (Rinvoq).
All of these medications can reduce the immune system's ability to fight infection and may affect how well surgical wounds heal. Decisions about stopping or continuing them are made on a case-by-case basis.
General ACR Guidance for Elective Surgery
For most conventional DMARDs (methotrexate, hydroxychloroquine, sulfasalazine): the 2022 ACR guideline recommends continuing these medications through elective orthopedic surgery in most patients, as stopping them increases the risk of disease flare without clear infection benefit.
For leflunomide: the decision to continue or hold it is made individually. Some rheumatologists recommend continuing; others hold it before high-infection-risk procedures.
For biologic DMARDs (TNF inhibitors, IL-6 inhibitors, IL-17 inhibitors, and others): the general recommendation is to withhold the medication for approximately one full dosing interval before elective surgery and restart it once the wound is healing without signs of infection (typically 2 weeks after surgery).
For JAK inhibitors: hold at least 3 days before elective surgery and restart when the surgical site is healing well without infection, generally within 2 weeks post-operatively.
For rituximab (Rituxan): because it has an extremely long effect lasting months, scheduling surgery 4 to 6 months after the last dose and timing any upcoming infusion after surgical healing is typical practice.
These are general guidelines. Your rheumatologist and surgeon must coordinate a specific plan based on your disease activity, surgical risk, and procedure type.
Risks of Stopping vs. Continuing
Stopping DMARDs or biologics before surgery can trigger a flare of your underlying condition, which itself causes inflammation that may impair healing.
Continuing these medications around surgery may increase the risk of surgical site infection, particularly for biologics and JAK inhibitors that significantly suppress immune function.
The risk of infection depends on the type of surgery. Low-risk procedures (minor soft-tissue surgery, dental work) carry different considerations than high-risk procedures (joint replacement, bowel surgery).
Do not stop any DMARD or biologic medication without discussing it with both your rheumatologist and your surgeon first. The decision requires balancing your disease stability against your surgical risk.
Practical Steps Before and After Surgery
Inform both your surgeon and your rheumatologist that surgery is planned as early as possible. They need to coordinate the timing of your last dose and your restart date.
Bring a complete medication list to all pre-operative appointments. Include dose, frequency, and the date of your last injection or infusion.
After surgery, watch closely for signs of wound infection: spreading redness, warmth, fever, or pus. Patients on immunosuppressive medications may develop infections that appear less obviously inflamed than in other patients.
Do not restart your biologic or JAK inhibitor on your own without confirming with your surgeon that the wound is healing adequately.
If you experience a disease flare in the period after surgery, contact your rheumatologist. Managing a flare with temporary low-dose corticosteroids may be safer than restarting your regular medication before the surgical site has fully healed.
Frequently asked
Questions patients ask.
Should I stop methotrexate before my hip replacement?
Current ACR guidance for elective orthopedic surgery recommends continuing methotrexate in most patients with well-controlled disease. Studies have not shown that stopping methotrexate before joint replacement surgery reduces infection rates, and stopping it can cause disease flares. Your rheumatologist and orthopedic surgeon should review your specific situation together.
When can I restart my Humira or Enbrel injection after surgery?
The general recommendation is to restart biologic injections after the surgical wound shows clear healing without signs of infection, typically around 2 weeks after surgery. Your surgeon should confirm the wound is healing well before you resume. Do not restart based on your regular injection schedule alone.
I forgot to tell my surgeon I take a biologic medication. What should I do?
Tell your surgeon or their office immediately, even if surgery is close. This information affects decisions about antibiotic prophylaxis, wound monitoring after surgery, and the safety of your procedure. It is never too late to share this information, and your care team will not be upset that you are disclosing it.
Does hydroxychloroquine (Plaquenil) need to be stopped before surgery?
No. Hydroxychloroquine does not significantly suppress the immune system in the way that other DMARDs and biologics do. ACR guidance supports continuing it through surgery. Stopping it carries risk of disease flare without benefit for surgical outcomes.
For patients
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This guide provides general information. For instructions tailored to your specific procedure, ask your provider about QR Rx care plans.
These medication guides are for educational purposes only and do not replace medical advice. Always follow your healthcare provider's specific medication instructions.
