| NSAIDs | Pain, inflammation in RA, SpA, gout | COX-1/COX-2 inhibition → decreased prostaglandin synthesis | GI bleeding, AKI, hypertension, cardiovascular events, platelet dysfunction. CV risk lower with naproxen. GI risk lower with celecoxib. | HOLD for: severe infection, AKI, GI bleeding, volume depletion, TBI/ICH, perioperative bleeding risk. Continue for: mild infections if renal function stable |
| Colchicine | Gout, CPPD, pericarditis, FMF | Microtubule inhibition → decreased neutrophil migration and inflammasome assembly | GI intolerance (5-8%), myelosuppression (rare), neuromuscular toxicity, rhabdomyolysis | HOLD for: severe infection, CrCl <30, severe hepatic dysfunction (Child-Pugh C), concurrent strong CYP3A4/P-gp inhibitors (clarithromycin, azoles, cyclosporine). Continue for: mild infections, stable disease |
| Allopurinol | Gout (first line ULT), hyperuricemia with cancer therapy, recurrent calcium oxalate stones | Xanthine oxidase inhibitor → blocks conversion of hypoxanthine to xanthine and xanthine to uric acid | Rash (most common), allopurinol hypersensitivity syndrome (AHS) (rare but potentially fatal: SJS/TEN, DRESS), hepatotoxicity, myelosuppression, AKI | HOLD for: new rash (evaluate for hypersensitivity), severe AKI (dose adjust or hold), severe hepatic dysfunction. HLA-B58:01 screening recommended in high-risk populations (Black Americans, Han Chinese, Thai, Korean) before starting. Avoid with azathioprine/6-mercaptopurine (increased toxicity) |
| Febuxostat | Gout (second-line ULT: inadequate response/intolerance of allopurinol) | Non-purine xanthine oxidase inhibitor → more potent than allopurinol; no dose adjustment needed in mild-moderate CKD | Hepatotoxicity, GI upset, rash, arthralgia, FDA black box warning: increased CV mortality | CONTINUE for: most admissions (stopping may trigger flare). HOLD for: ALT/AST >3× ULN (investigate cause), serious skin reactions, acute CV event. Avoid with azathioprine/6-mercaptopurine (increased toxicity) |
| Methotrexate | RA, PsA, SLE, vasculitis | Increases extracellular adenosine at low doses used for rheumatologic indications | Hepatotoxicity, cytopenias, pneumonitis (rare in RA), mucositis, nausea | Continue for: stable patients, perioperatively. HOLD for: active infection (especially respiratory), severe cytopenias, transaminases >3× ULN, AKI. Supplement with folic acid to reduce toxicity. Monitor CBC, LFTs, Cr q3-4 months |
| Leflunomide | RA, PsA | Pyrimidine synthesis inhibitor | Hepatotoxicity, diarrhea, alopecia, hypertension, cytopenias | Continue for: stable patients. HOLD for: active infection, severe hepatic dysfunction, cytopenias. Monitor CBC, LFTs, Cr. Cholestyramine washout if toxicity/unexpected pregnancy. |
| Sulfasalazine | RA, SpA, IBD | 5-ASA + sulfapyridine → anti-inflammatory | GI upset, rash, hepatotoxicity, cytopenias, oligospermia | Continue for: most admissions including perioperatively. HOLD for: severe infection, severe cytopenias. Monitor CBC, LFTs, Cr q3-4 months |
| Hydroxychloroquine | RA, SLE | Lysosomal pH alteration → immune modulation | Retinopathy (rare 1%), cardiomyopathy, QT prolongation, GI upset | Continue for: most admissions including perioperatively, even with infections. No infection risk. Caution with CKD → higher risk of toxicity. Monitor: baseline and annual eye exams, periodic CBC |
| Azathioprine | SLE, vasculitis, myositis | Purine analog → inhibits DNA synthesis | Myelosuppression, hepatotoxicity, pancreatitis, increased malignancy risk | HOLD for: active infection, severe cytopenias, perioperatively. Continue for: stable patients without infection. Check TPMT before starting. Monitor CBC, LFTs q3-4 months |
| Mycophenolate | SLE, LN, ILD, vasculitis, myositis | Inhibits inosine monophosphate dehydrogenase → lymphocyte proliferation | GI upset, myelosuppression, increased infection risk | HOLD for: active infection, perioperatively. Continue for: stable patients without infection. Monitor CBC q3-4 months |
| Calcineurin inhibitors (cyclosporine, tacrolimus, voclosporin) | LN, myositis | Inhibit calcineurin → suppress IL-2 and T-cell activation; stabilize podocytes | Nephrotoxicity, HTN, hyperkalemia, hypomagnesemia, tremor. Cyclosporine: gingival hyperplasia, hirsutism, hyperlipidemia. Tacrolimus: hyperglycemia/DM. Voclosporin: QT prolongation | CONTINUE for: stable patients, perioperatively (case-by-case). HOLD for: active serious infection, AKI (Cr↑>25-30%), severe HTN, neurotoxicity. Monitor: Trough levels (cyclosporine/tacrolimus; voclosporin does NOT require monitoring), Cr, BP, K+, Mg2+, glucose, LFTs. Drug interactions: Avoid grapefruit; caution with CYP3A4 inhibitors |
| TNF Inhibitors (adalimumab, etanercept, infliximab, golimumab, certolizumab) | RA, PsA, SpA, IBD | TNF-α blockade → decreased inflammation | Serious infections (TB, fungal), malignancy, demyelination, CHF exacerbation, lupus-like syndrome | HOLD for: active infection (restart 7-14 days after symptom resolution). Continue perioperatively (hold 1 dosing interval before surgery). Screen for TB, hepatitis B/C at baseline |
| IL-17 Inhibitors (secukinumab, ixekizumab, brodalumab, bimekizumab) | PsA, SpA, psoriasis | IL-17 blockade → inhibits Th17-mediated inflammation at entheses, skin, joints | Mucocutaneous candidiasis, upper respiratory infections, injection site reactions, new-onset or exacerbation of IBD (avoid in active IBD), neutropenia (rare), hepatotoxicity (rare). | CONTINUE for: low-risk procedures, mild infections, perioperatively (case-by-case). HOLD for: active serious infection, active IBD or new GI symptoms (bloody diarrhea), severe neutropenia. Absolute contraindications: Active IBD, active TB, bacterial infection, hepatitis B. Restart 7-14 days after infection resolution. Monitor: Periodic assessment for infections, IBD symptoms, suicidal ideation (brodalumab) |
| IL-6 Inhibitors (tocilizumab, sarilumab) | RA, GCA, SJIA/AOSD, PMR | IL-6 receptor blockade | Serious infections, GI perforation, diverticulitis, hepatotoxicity, cytopenias, hyperlipidemia | HOLD for: active infection, diverticulitis. CRP not a reliable inflammatory marker while on IL-6 inhibitors (suppressed). Monitor CBC, LFTs at 4-8 weeks then q3 months; lipids at weeks 4, 8 then q6 months |
| IL-1 Inhibitors (anakinra, canakinumab) | SJIA/AOSD, autoinflammatory syndromes, gout, HLH | IL-1 blockade | Injection site reactions (anakinra), neutropenia, increased infection risk | May continue for: autoinflammatory conditions even with mild infection (case-by-case). HOLD for: severe infection. Monitor CBC monthly x3 months then q3 months |
| Anti-CD20 (rituximab, obinutuzumab) | RA, vasculitis, SLE, LN | B-cell depletion | Infusion reactions, hypogammaglobulinemia, cytopenias | HOLD for: active infection. Dosed q6 months; plan surgery in month 7. Monitor CBC q2-4 months. Screen for hepatitis B. Vaccination prior to initiation. |
| Belimumab | SLE, LN | BLyS (B-lymphocyte stimulator)-inhibitor → inhibits B-cell survival | Infusion/injection reactions, infections, depression/psychiatric events, hypersensitivity. | CONTINUE for: most admissions, perioperatively. HOLD for: active serious infection, severe hypersensitivity reaction. Restart after infection resolution. |
| JAK Inhibitors (tofacitinib, baricitinib, upadacitinib) | RA, PsA, SpA, UC, GCA | JAK-STAT pathway inhibition | Herpes zoster, serious infections, MACE (age >50 with CV risk), VTE, malignancy, hyperlipidemia | HOLD for: active infection (restart 7-14 days after resolution). Hold 3-7 days preoperatively. Monitor CBC, LFTs at 4-8 weeks then q3 months; lipids at 4-8 weeks then q6 months |
| Complement Inhibitors (avacopan, eculizumab, ravulizumab) | Avacopan: ANCA-associated vasculitis. Eculizumab/Ravulizumab: PNH, aHUS, AChR+ myasthenia gravis, NMOSD (AQP4+) | Avacopan: C5a receptor antagonist (does not block MAC). Eculizumab/Ravulizumab: Anti-C5 monoclonal antibodies blocking terminal complement (MAC formation) | Avacopan: Hepatotoxicity, nausea, headache. Eculizumab/Ravulizumab: BLACK BOX—meningococcal infection; headache, URI, nausea | Continue during hospitalization (flare risk if held). Eculizumab/Ravulizumab: Maintain meningococcal prophylaxis (penicillin or ciprofloxacin); requires MenACWY + MenB vaccination; if febrile → urgent meningococcal evaluation |
