Medications
Methotrexate Before Surgery
Methotrexate is a weekly medicine for rheumatoid arthritis and psoriasis, and for most routine operations it is safely continued rather than stopped. Here is how the stop-or-continue decision is usually made.
Quick answer
It may be paused for major surgery, or if your kidney function is reduced (methotrexate is cleared by the kidneys). One key safety point: methotrexate is taken once a WEEK (weekly), never daily — so confirm your exact day and dose. Your rheumatologist and surgeon make the final call together. See our medications to stop before surgery guide.
Why it matters
Methotrexate calms an overactive immune system. In rheumatoid arthritis and psoriasis it is the background medicine that keeps joints and skin under control. Because it works slowly over weeks, stopping it briefly does not give a quick safety benefit — but it can let the underlying disease flare, leaving you stiff, sore and harder to rehabilitate just when you need to move after surgery.
For years surgeons worried that immune-calming drugs would cause wound infections. For methotrexate at normal weekly doses, that worry has not held up. Randomised and observational studies in people with rheumatoid arthritis having joint and other operations found no increase in infection or wound-healing problems when methotrexate was continued, and fewer flares compared with stopping it. That is why major rheumatology and anaesthetic guidance now leans toward continuing it for routine surgery.
The picture changes with bigger operations, heavy expected blood loss, or reduced kidney function. Methotrexate leaves the body through the kidneys, so if kidney function drops — which can happen around major surgery — levels can build up and cause toxicity. In those situations your team may hold a dose or two. This is a judgement call that balances your specific surgery, your kidney numbers and your disease activity, which is why it is individualised rather than one-size-fits-all.
Do not stop without instruction
The decision needs coordination because it depends on the size of your surgery, your kidney function and your other medicines (especially if you also take a biologic or steroids). Let the people doing your pre-op medication check know you take it, on which day of the week, and at what dose — then follow the plan they give you. If you also manage diabetes, see our diabetes tablets before surgery guide for those separately.
What to ask your doctor
- Given the size of my operation, should I continue my weekly methotrexate or hold a dose — and have you checked this with my rheumatologist?
- What is my current kidney function, and does it change the plan for methotrexate?
- Which exact day is my methotrexate dose, and is the one falling closest to surgery the one we keep or skip?
- Do any of my other medicines (a biologic, steroids, or new tablets) change what I should do with methotrexate?
Red flags — call your team
Red flags — call your team
- You realise you have accidentally taken methotrexate DAILY instead of once weekly — contact a doctor or pharmacist urgently, as daily dosing can be dangerous.
- Mouth ulcers, unusual bruising or bleeding, a sore throat with fever, or feeling suddenly very unwell — possible signs of methotrexate toxicity needing prompt review.
- After surgery: a wound that becomes hot, red, increasingly painful or starts leaking, or a fever — report it to your surgical team rather than waiting.
References
- General guidance from rheumatology and perioperative sources (e.g. the American College of Rheumatology / American Association of Hip and Knee Surgeons (ACR/AAHKS) perioperative recommendations) supports continuing weekly methotrexate through routine surgery in rheumatoid arthritis, with individualised pausing for major surgery or renal impairment.
- These are general guidelines for education only. Your own surgical, anaesthetic and rheumatology team's instructions always take precedence over anything on this page.
Frequently asked questions
Will continuing methotrexate make my surgical wound get infected?
For weekly methotrexate at usual doses, the evidence says no. Studies in people with rheumatoid arthritis having operations found that continuing it did not raise infection or wound-healing problems, while stopping it led to more disease flares. That is why many teams now continue it for routine surgery. Major operations or poor kidney function are handled differently, so always follow your own team's specific plan.
It is only once a week — should I take my dose if it lands on surgery day?
Ask your team rather than deciding alone. Because methotrexate is weekly, the dose nearest your operation is the one that matters, and plans vary: many people simply continue as normal for routine surgery, while others are asked to shift or skip that single dose for major surgery or reduced kidney function. Tell them which day you take it so the timing is planned deliberately, not by chance.
Why does kidney function keep coming up with methotrexate?
Because your kidneys are how methotrexate leaves your body. If kidney function drops — which can happen around major surgery, blood loss or dehydration — the drug can build up and cause toxicity such as mouth ulcers, low blood counts or feeling very unwell. That is why your team may check your kidney numbers and, for bigger operations, hold a dose. For routine surgery with normal kidneys, continuing is usually fine.
What happens to my arthritis if I stop methotrexate before surgery?
Methotrexate works slowly, so stopping it does not help your surgery but can let the disease flare over the following weeks — meaning more joint pain, stiffness and swelling, or a psoriasis flare, right when you are trying to recover and move. That trade-off is exactly why continuing is preferred for routine operations. If a pause is genuinely needed for a major procedure, your team will plan how and when to restart it.