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Biologic DMARD Perioperative Management — FRCA Final MCQ

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HardPreoperative AssessmentBiologic DMARD Perioperative ManagementFRCA Final

A 55-year-old woman (ASA III) with rheumatoid arthritis on methotrexate 15 mg weekly and adalimumab (anti-TNF) fortnightly requires a total knee replacement. Regarding perioperative management of her immunosuppressive therapy, what is current guidance?

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Correct answer: C — Continue methotrexate; withhold adalimumab for one dosing cycle before and after surgery

Current BSR guidelines (2022) recommend: CONTINUE conventional DMARDs (methotrexate, sulfasalazine, hydroxychloroquine) through the perioperative period – stopping methotrexate does NOT reduce surgical site infection risk and may cause disease flare. WITHHOLD biologic agents (adalimumab, etanercept, infliximab etc.) for one dosing cycle before surgery and restart when wound healing is satisfactory (typically 2 weeks post-operatively). This approach balances infection risk from immunosuppression against disease flare from drug withdrawal.

Reference: BSR – 2022 – Perioperative management of immunosuppressive drugs; NICE – 2018 – NG100 RA management