Disease-Modifying Antirheumatic Drug – DMARD

  Issues for Surgery

For rheumatology and dermatology conditions – risk of perioperative flare in disease activity if omitted (see Further Information).

Risk of post-operative infection if continued (see Further Information).

  Advice in the Perioperative period

Elective Surgery 

Rheumatology Indications 

Individualised decisions should be made for procedures considered to have a high risk of infection1 and should be balanced against the risk of disease flare (see Further Information). The Surgical Team and the patient’s Rheumatologist should be involved in the planning.

Steroid exposure should be minimised prior to surgical procedures, and increases in steroid dose to prevent adrenal insufficiency are not routinely required1.

Dermatology Indications
The decision to continue should be made on an individual patient basis in conjunction with the Surgical Team and the patient’s specialist.

If the decision is made to stop hydroxychloroquine prior to surgery, it should be stopped 2 weeks pre-operatively1.

Emergency Surgery

The patient should be closely monitored for signs of infection following emergency surgery.

Post-operative Advice

If discontinued, restart once wound healing is satisfactory1.

Where hydroxychloroquine is continued, close monitoring of renal function is important so that inadvertent drug accumulation does not occur1.

  Interaction(s) with Common Anaesthetic Agents

Neuromuscular Blocking Drugs (NMBDs)

A report described respiratory insufficiency during the recovery period following surgery, which was attributable to the additive effects of chloroquine with NMBDs. Hydroxychloroquine would be expected to interact similarly. Monitor the outcome of concurrent use, expecting an alteration in recovery time2.

  Interaction(s) with other Common Medicines used in the Perioperative Period

QT-Interval Prolongation

Hydroxychloroquine may increase the QT-interval, although there is no evidence of such an effect. Some consider concurrent use with other drugs that can prolong the QT-interval might increase the risk. These include2:-

  • ciprofloxacin*
  • clarithromycin*
  • domperidone**
  • droperidol*
  • erythromycin – particularly intravenous*
  • granisetron**
  • haloperidol*
  • loperamide – increased risk with high doses*
  • ondansetron*
  • prochlorperazine – only a theoretical risk*

*monitor ECG with concurrent use if risk factors for QT-interval prolongation also present (increasing age, female sex, cardiac disease, and some metabolic disturbances e.g. hypokalaemia)
** no documented reaction, but bear interaction in mind especially in presence of additional risk factors

Antimicrobials (see also under QT-Interval Prolongation above)

Aminoglycoside antibiotics (e.g. gentamicin) could potentiate the direct blocking action of hydroxychloroquine at the neuromuscular junction3.

Whilst single surgical prophylactic doses should not pose a problem, continued post-operative treatment may require close monitoring. Consult current product literature.

  Further Information


Rheumatoid Arthritis (RA) Flare

RA flares develop in 10-20% of patients undergoing surgery and have a potential to impact adversely on post-operative recovery. In addition, active RA increases infection risk, further complicating decisions regarding DMARD interruption1.

Infection Risk

Some data suggest that not all DMARDs carry equivalent infection risk profiles. In a retrospective study looking at joint surgeries in RA patients, two-thirds of patients receiving DMARDs including hydroxychloroquine demonstrated no association with perioperative infection1. Specialists do not consider hydroxychloroquine to be an immunosuppressant and as such recommend that it can be safely continued throughout the perioperative period irrespective of the infection risk associated with the surgery.



  1. Ledingham J, Gullick N, Irving K et al. Rheumatology Guidelines. The British Society of Rheumatology and British Health Professionals in Rheumatology. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs. Rheumatology. 2017; 56(6):865-68 and online supplementary information www.rheumatology.oxfordjournals.org [Accessed on 26th June 2019]
  2. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 26th June 2019]
  3. Summary of Product Characteristics – Plaquenil®- Hydroxychloroquine sulphate 200mg Film-coated Tablets. Zentiva. Accessed via www.medicines.org.uk 26/06/2019 [date of revision of the text August 2018]