Inflammatory Arthritis Treatment: Stopping or Continuing DMARDs Around Surgery

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Patients with inflammatory arthritis face a complex clinical decision when scheduling elective orthopedic surgery: whether to continue or temporarily discontinue disease-modifying anti-rheumatic drugs (DMARDs). Recent evidence suggests that while discontinuing these medications may increase the risk of a disease flare, there is no clear statistical benefit regarding the reduction of postoperative infection rates.

Key Clinical Takeaways:

• Discontinuing DMARDs around the time of surgery correlates with a 37% higher incidence of disease flares compared to continuing treatment.
• Current evidence indicates that stopping DMARDs provides no significant reduction in the risk of postoperative infections or wound complications.
• Clinical decision-making should prioritize individualized care, as current data on long-term functional outcomes and prosthetic joint infections remains insufficient.

The Clinical Dilemma of Immunomodulation in Surgery

Inflammatory arthritis—encompassing conditions such as rheumatoid arthritis, psoriatic arthritis, and axial spondyloarthritis—is characterized by systemic immune dysregulation. The pathogenesis of these diseases involves chronic inflammation that targets synovial tissues, leading to irreversible joint degradation. DMARDs serve as the standard of care to mitigate this inflammation. However, because these agents function by modulating the immune system, clinicians have long debated their potential to impair postoperative healing or increase susceptibility to surgical site infections.

A systematic review updated in March 2025 by the Cochrane Library analyzed data from 306 patients across three studies, providing a clearer look at the risks associated with perioperative medication management. The analysis focused on patients with rheumatoid arthritis undergoing planned orthopedic procedures. The findings suggest that the strategy of “holding” medication, intended to reduce infection risk, may be offset by the physiological stress of a disease flare.

Comparative Outcomes: Flare Risk vs. Infection Rates

The data highlights a significant disparity between the perceived risk of infection and the observed risk of disease activity. In the reviewed cohorts, 37% of patients who discontinued their DMARDs experienced a flare, whereas no flares were reported in the group that maintained their medication regimen. This underscores the potential for rapid disease reactivation when systemic immunomodulation is abruptly halted.

Conversely, the data regarding surgical safety metrics—such as postoperative infections and wound complications—showed negligible differences between the two groups. Specifically, infection rates remained low and comparable regardless of whether the DMARD was continued or paused.

Limitations in Current Evidence

While the findings provide a baseline for clinical practice, the evidence base is constrained by several factors. The studies included in the review were primarily open-label, meaning patients were aware of their treatment allocation, which may introduce reporting bias concerning subjective outcomes like disease flares. Furthermore, the studies focused exclusively on conventional synthetic DMARDs, leaving a gap in understanding how biological or targeted synthetic DMARDs interact with surgical recovery.

Critical endpoints, such as long-term prosthetic joint survival and validated disease activity scores, were largely absent from the available literature. According to research published in the Cochrane Database of Systematic Reviews, the lack of large-scale, double-blind, placebo-controlled trials makes it difficult to establish a universal “standard of care” for all inflammatory conditions.

Future Directions for Personalized Orthopedic Care

Future research must prioritize the assessment of quality-of-life metrics and objective functional recovery to better guide clinical practice.

As this remains a living systematic review, practitioners should continue to monitor updates from the Cochrane Database of Systematic Reviews to ensure their surgical protocols reflect the latest available data.

Disclaimer: The information provided in this article is for educational and scientific communication purposes only and does not constitute medical advice. Always consult with a qualified healthcare provider regarding any medical condition, diagnosis, or treatment plan.