Background: In recent years, the number of patients with rheumatoid arthritis (RA) who underwent orthopaedic joint surgery while using Janus kinase inhibitors (JAKi) has been increasing. In Japan, there are no established guidelines for perioperative discontinuation of JAKi, therefore, we had routinely discontinued JAKi 7 days before surgery following the 2017 American College of Rheumatology and American Association of Hip and Knee Surgeons guideline. However, we frequently observed cases with flare-ups of RA disease activity during the perioperative period. In 2022, this guideline was revised to suggest a 3-day preoperative discontinuation period for JAKi in patients who underwent total knee arthroplasty or total hip arthroplasty. Since January 2023, we adopted a 1- to 3-day preoperative discontinuation period, considering the half-life of each drug.

Objectives: The aim of this study was to evaluate the influence of perioperative discontinuance of JAKi in patients with RA who underwent joint surgery.

Methods: We retrospectively analyzed 26 patients with RA (36 surgeries) who underwent orthopedic joint surgeries under general anesthesia while using JAKi at our hospital since 2016. The study included 20 female patients (29 surgeries) and 6 male patients (7 surgeries). The incidences of perioperative flare-ups of RA symptoms and postoperative surgical site infections (SSI) were retrospectively investigated from the medical records.

Results: The average age at the time of surgery was 67.4 years (range: 44–84). The medications used were tofacitinib in 11 surgeries, baricitinib in 11 surgeries, upadacitinib in 9 surgeries, filgotinib in 4 surgeries, and peficitinib in 1 surgery. Flare-ups of RA symptoms during the discontinuation of JAKi were observed in 9 surgeries (25%). In the 9 cases with flare-ups of RA, preoperative DAS28-ESR significantly higher (flare-ups group: 3.58 vs. no flare-ups group: 2.54, p<0.01) and preoperative discontinuation period was significantly longer (flare-ups group: 6.3 days vs. no flare-ups group: 3.9 days, p=0.03) than in 27 cases without flare-ups. Preoperative rheumatoid factor (RF) also showed a tendency for higher levels in the flare-ups grous (flare-ups group: 391.5 IU/ml vs. no flare-ups group: 119.8 IU/ml, p=0.06). As for preoperative discontinuation period, comparing long-term (7 days, 18 surgeries) and short-term (1–3 days, 18 surgeries) groups, flare-ups occurred in 8 surgeries (44.4%) in the long-term group and one surgery (5.6%) in the short-term group, showing a significant difference (p=0.02). Postoperative SSIs were observed in 3 surgeries (8.3%): one each for open reduction of olecranon fracture, wrist arthroplasty, and wrist arthrodesis. Flare-ups were also observed in one case with SSI of wrist arthroplasty. SSI occurred in one surgery (5.6%) in the long-term group and two surgeries (11.1%) in the short-term group, which showed no significant difference between the groups.

Conclusion: Flare-ups of RA symptoms during JAKi discontinuation were observed in 25% of the cases, with longer preoperative discontinuation periods and higher preoperative disease activity associated with flare-ups. From these results, preoperative disease activity should be well controlled to prevent flare-ups of RA symptoms, even in patients undergoing surgery while using JAKi. On the other hand, the incidence rate of SSI was 8.3%, which is higher than the general infection rate for clean orthopedic surgeries (0.5–2%). Although it remains unclear whether JAKi increases the risk of SSI, they could potentially act as risk factors for SSI, similar to biologic agents. Considering the risks of flare-ups and SSI, the appropriate perioperative discontinuation period for JAKi will be continuously discussed.

REFERENCES: [1] Susan M Goodman et al. J Arthroplasty, 2017.

[2] Susan M Goodman et al. Arthritis Care Res, 2022.

Acknowledgements: NIL.

Disclosure of Interests: None declared.

© The Authors 2025. This abstract is an open access article published in Annals of Rheumatic Diseases under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ). Neither EULAR nor the publisher make any representation as to the accuracy of the content. The authors are solely responsible for the content in their abstract including accuracy of the facts, statements, results, conclusion, citing resources etc.