Question
For an rheumatoid arthritis patient on methotrexate (MTX) and scheduled for surgery, should MTX be discontinued prior to the surgery? If so, why? What is the time scale for the discontinuation, and when can MTX be reintroduced?
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Response from Stanley B. Cohen, MD Clinical Professor, UT Southwestern Medical Center Dallas, Dallas, Texas; Medical Director, Metroplex Clinical Research Center, Dallas, Texas |
The issue raised is whether MTX must be discontinued temporarily in the perioperative period. It is my impression that most rheumatologists discontinue MTX during the perioperative period -- generally the week of surgery and for 1-2 weeks post surgery. However, several randomized nonblinded studies and 1 large observational cohort study demonstrated no increase in risk for perioperative infections in individuals maintained on MTX compared with those either not receiving MTX or in whom MTX was discontinued preoperatively. In addition, discontinuing MTX may result in a disease flare which could affect postoperative recovery.
In summary, the limited evidence does not support a need to discontinue MTX in rheumatoid arthritis patients undergoing surgery. However, there is no consensus on what is "best practice," and the approach at present is empirical, with both approaches considered appropriate.