What are the benefits and risks of stopping or continuing DMARD medicines (disease-modifying anti-rheumatic drugs) around the time of surgery in people with inflammatory arthritis?

Key messages

• A common treatment for inflammatory arthritis is a medicine that alters the immune system and so reduces inflammation (DMARDs). Stopping DMARD treatment around the time of surgery to treat an affected joint may increase people's risk of experiencing a flare (worsening symptoms), but may make no difference to their likelihood of developing an infection or experiencing an unwanted event after the operation.

• More studies are needed to assess the effects of stopping or continuing DMARDs on disease activity, function, and quality of life.

What is inflammatory arthritis?

Inflammatory arthritis (including rheumatoid arthritis, psoriatic arthritis and axial spondyloarthritis) is a chronic (persistent) condition that causes abnormal inflammation in the joints, ligaments (connective tissue), and tendons (which attach muscle to bone), resulting in pain, stiffness, swelling, and loss of function. It is a progressive disease that, if uncontrolled, may result in irreversible joint damage, significantly impaired function and quality of life, and inability to work.

How is inflammatory arthritis treated?

Inflammatory arthritis is treated with medicines called 'disease-modifying anti-rheumatic drugs' or 'DMARDs' that control the inflammation, thus reducing symptoms (pain, swelling, or stiffness) and preventing joint damage.

However, since DMARDs alter the immune system, they may also increase the risk of infection, including surgical site infections.

What did we want to find out?

We aimed to find out about the benefits and risks of stopping compared to continuing DMARDs around the time of surgery in people with inflammatory arthritis. We were interested in:

• flare (worsening symptoms or increased disease activity)

• infections after surgery

• infection in the artifical (prosthetic) joint

• disease activity score (from questionnaires)

• function (measured by questionnaire)

• unwanted events (such as wound problems or complications from surgery)

What did we do?

We searched for studies that investigated the effects of stopping or continuing DMARDs around the time of surgery. People in the studies had to be adults with inflammatory arthritis. They could be undergoing any type of surgery except for emergency or unplanned surgery.

We compared and summarised the results and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found three studies with 306 people. All had rheumatoid arthritis and had been taking conventional synthetic (man-made) DMARDs for more than 10 years. They were all undergoing planned orthopaedic surgery, that is, surgery on bones, joints and tendons. Their average age was 56 years, and 83% were women. Studies were conducted in France, the UK and Japan. One trial reported receiving funding from a foundation unrelated to commercial purposes and two studies did not report funding sources.

Main results

Compared with continuation of DMARDs during surgery:

• discontinuation may increase the risk of flare: 37% more people had a flare or worsening of the underlying disease activity when stopping DMARDs during surgery compared to those who continued with DMARDs (2 studies, 224 people). Out of 100 people who continued DMARDs, none reported a flare, compared to 37 out of 100 people who stopped DMARDs;

• discontinuation may have little or no effect on postoperative infections: 0% fewer people had postoperative infections when stopping DMARDs (3 studies, 306 people). Out of 100 people who continued DMARDs, 3 had postoperative infections compared to 3 out of 100 people who stopped with continuation of DMARDs.

• only one study (64 people) reported postoperative joint infections, with no infections in people who continued or stopped DMARDs.

• discontinuation may have little or no effect on total unwanted events, such as problems with the wound (3 studies, 306 people) or serious unwanted events, such as need for further surgery or procedures (2 studies, 242 people); 9% more people reported an unwanted event and 2% more people reported a serious unwanted event when stopping DMARDs.

What are the limitations of the evidence?

We have little confidence in the evidence because we found only three studies, and people in the studies were aware of which treatment they were getting. This may affect their reporting of disease flare, unwanted events and serious unwanted events, but it probably does not affect how they reported postoperative infections. None of the studies measured prosthetic joint infections, disease activity and function, so we don't know the effect of stopping DMARDs around the time of surgery on them. We only found studies on one type of DMARD.

How up to date is this evidence?

The evidence is up-to-date to 24 March 2025.

Editorial note: This is a living systematic review. We search for new evidence approximately yearly and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.