Methotrexate is a weekly disease-modifying medication used for rheumatoid arthritis, psoriasis, psoriatic arthritis, and several other autoimmune conditions. Coordinating methotrexate around surgery has been studied extensively. Most patients can continue their usual dose, but some procedures and patient situations call for a brief hold. Knowing the recommendations helps you avoid unnecessary disease flares while protecting your wound.
How Methotrexate Works
Methotrexate is taken weekly (oral or injection) at low doses for autoimmune disease. Higher daily doses are used in some cancer treatments; this guide focuses on the weekly low-dose use.
It interferes with folate metabolism and modulates immune signaling. The result is reduced inflammation, less joint damage, and slower disease progression.
Most patients also take folic acid (1 mg daily) or folinic acid (a higher dose once weekly) to reduce methotrexate side effects without losing efficacy.
The drug stays active in the body for several days. Holding one weekly dose typically returns disease activity within 2 to 3 weeks if the medication is restarted promptly.
Current Surgical Recommendations
The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) jointly recommend continuing methotrexate through elective surgery, including hip and knee replacement, in most patients.
Continuing methotrexate has not been shown to increase wound infection or delayed healing in clinical studies, and stopping it raises the risk of disease flare.
Exceptions where holding may be considered: patients with kidney impairment that worsens around surgery, patients with active infection at the surgical site, and major procedures where the surgeon and rheumatologist together decide a hold is preferable.
If methotrexate is held, the typical pattern is to skip 1 dose before surgery and resume after the wound shows signs of good healing (typically 2 weeks).
Talking to Your Surgeon and Rheumatologist
Tell every clinician (surgeon, anesthesiologist, primary care, dental) about methotrexate. Bring the dose, route, and last weekly dose timing.
Ask whether your specific procedure justifies a hold. The default is continue, but the answer is procedure and patient specific.
Confirm what to do if your surgery is delayed. If you held a dose for a planned surgery and the surgery is rescheduled, ask whether to resume the missed dose or wait for the new surgical date.
Coordinate folic acid as well. Folic acid is generally continued through the perioperative period.
Watch For Side Effects During Recovery
Mouth sores can flare during recovery, particularly if dehydration occurs. Stay hydrated and use folic acid as prescribed.
Liver enzymes can rise during illness or stress. Routine labs typically continue at your rheumatologist's usual interval. Tell your surgeon if you have any history of significant liver test changes on methotrexate.
Avoid alcohol around surgery. Alcohol plus methotrexate increases liver risk.
Use the QRRX care plan to log methotrexate doses, folic acid doses, and any new symptoms. Trends help your rheumatologist adjust treatment.
Frequently asked
Questions patients ask.
Will methotrexate slow my wound healing?
Studies of weekly low-dose methotrexate around major orthopedic surgery have not shown a meaningful difference in wound healing or infection. The current rheumatology and surgery consensus is that continuing the drug is safe for most patients. Higher cancer-treatment doses are a different conversation.
Should I take methotrexate if I get an infection after surgery?
Hold methotrexate while you have an active infection and resume only after the infection is treated. Tell both your surgeon and your rheumatologist about the infection so they can coordinate timing. Keep folic acid going during the hold.
Is it safe to take ibuprofen with methotrexate around surgery?
Standard NSAID doses generally do not require holding methotrexate. High doses of NSAIDs combined with kidney impairment can raise methotrexate levels and increase toxicity risk. Discuss any new pain medication with your rheumatologist if you are unsure.
For patients
Get a personalized care plan.
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.
