"Hydroxychloroquine (or Plaquenil) is felt to be safe during the preoperative period. It is recommended to continue this medication without stopping," Dr. Grant said.
There is conflicting information on infection risk with the use leflunomide (Arava), but it may be wise to stop therapy 2-4 weeks before nonurgent surgery in higher-risk patients.
There is consensus that sulfasalazine (Azulfidine) and azathioprine (Imuran) can be safely continued perioperatively, he said, although some advise holding sulfasalazine on the day of surgery.
Regarding perioperative steroids, Dr. Grant recommended determining the patient’s steroid exposure over the past year.
"Stress dose steroids are not routinely needed as long as the patients continue their normal dose.
"That’s really the important piece: If someone’s taking prednisone every day, make sure they take at least that dose on the day of surgery," he said.
Dr. Lary Robinson, FCCP, comments: Surgeons are rightfully concerned about the preoperative use of any medicines that might increase the risk of bleeding, infections or wound healing. The topic of immunomodulating drugs was explored by evaluating the published evidence about their safety in the perioperative period. These agents, used in patients with autoimmune/inflammatory diseases such as rheumatoid arthritis and Crohn's disease, are generally safe to continue although most authorities generally recommend holding the TNF-alpha antagonists prior to and after major surgery due to potential wound healing and infectious problems.