Stopping arthritis drugs before surgery may raise flare risk

People with inflammatory arthritis often face a tough choice before surgery. Should they stop their daily medication to prevent infection, or keep taking it to avoid a disease flare? A new living systematic review looked at this exact question for adults with rheumatoid arthritis, psoriatic arthritis, or axial spondyloarthritis. The study examined thirty-six participants in randomized trials and nine observational studies. It focused on drugs like methotrexate and leflunomide, known as conventional synthetic DMARDs. The review found that stopping these drugs before elective orthopaedic or non-orthopaedic surgery may increase the risk of a disease flare. In the data, thirty-six percent of patients who stopped their drugs experienced a flare, while none of those who continued their medication did. The evidence for this finding is rated as low certainty, meaning the results are not perfectly clear but point in this direction. The review also looked at postoperative infections and found little or no effect from stopping the drugs. Rates were three percent in both groups. Total adverse events and serious adverse events showed a wide range of uncertainty, with some numbers suggesting a possible increase but the data being too shaky to be sure. Only one trial measured prosthetic joint infections, and it reported no infections in either group. The study has important gaps. It did not find any trials for adults with rheumatoid arthritis undergoing non-orthopaedic surgery or for those with psoriatic arthritis or axial spondyloarthritis undergoing any surgery. It also lacked data on disease activity scores or function at follow-up. These missing pieces mean doctors cannot yet give a single clear answer for every patient. The evidence is limited to specific drug types and conditions. For biologic or targeted synthetic DMARDs, the risks associated with stopping them are less clear. Observational data suggests that stopping these drugs does not reduce the likelihood of prosthetic joint infections. Until more data arrives, patients and doctors must weigh the risk of a flare against the fear of infection carefully.