Most biologics should be stopped for one full dosing cycle before elective surgery. If you take a biologic every two weeks, you’d skip one dose so the drug clears your system before your procedure date. The exact timing varies by medication, ranging from about one week for fast-acting drugs to several months for those that linger in your body longer. The most widely referenced guidance comes from the 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons (ACR/AAHKS) guideline, which remains the standard through 2025.
The Core Rule: One Dosing Cycle
The simplest way to think about biologic timing is to schedule your surgery at the end of your normal dosing cycle, right before your next dose would be due. This “one dosing interval” approach is the backbone of current guidelines. If you inject a medication every four weeks, you’d plan surgery about four weeks after your last dose. If you take something every two weeks, surgery would fall roughly two weeks after your last injection.
This rule exists because biologics suppress parts of your immune system, and surgery introduces infection risk through open wounds. Letting the drug clear gives your immune defenses a better chance of fighting off bacteria during the healing window. The general pharmacologic principle is that a biologic should be withheld for at least two half-lives before major surgery, though some dental and dermatology guidelines use a more conservative window of four to five half-lives.
Timing for TNF Inhibitors
TNF inhibitors are the most commonly used biologics before surgery, and their hold times vary considerably because their half-lives differ. Etanercept clears the fastest, with a half-life of about 3.5 days. Two half-lives works out to roughly one week, so a hold period of 2 to 4 weeks before surgery is typical. In practice, most patients simply skip one dose.
Adalimumab has a longer half-life of 10 to 20 days. The recommended discontinuation window is broader, generally 2 to 8 weeks before surgery depending on the procedure and the patient’s condition. Infliximab, given by infusion rather than self-injection, has a half-life of about 8 to 10 days, and is commonly stopped about 4 weeks before surgery. Because infliximab is dosed less frequently (typically every 6 to 8 weeks), many patients are simply scheduled for surgery at the tail end of their infusion cycle. Golimumab follows a similar 4-week hold.
Rituximab Requires the Longest Window
Rituximab stands apart from other biologics because it depletes a type of immune cell (B cells) that takes months to recover. Guidelines recommend scheduling surgery 3 to 7 months after a rituximab infusion. Some rheumatologists check B-cell levels directly and time surgery based on immune recovery rather than a fixed calendar window. In studies of patients undergoing joint replacement, the median time between rituximab infusion and surgery was about 6.5 months regardless of whether complications occurred, suggesting that most surgical teams already build in a long buffer.
Other Biologics and Newer Agents
Abatacept, which targets T cells, has a half-life of about 14 days and is generally held for 2 to 3 weeks before surgery. A registry study of over 1,500 patients undergoing hip or knee replacement found that those who received abatacept within 4 weeks of surgery had similar infection and readmission rates to those who stopped it earlier, which is somewhat reassuring but hasn’t changed the official recommendation to hold for one dosing interval.
For IL-17 inhibitors like secukinumab and ixekizumab, and the IL-12/23 inhibitor ustekinumab, guidance is less well established. The available recommendations suggest planning surgery at the end of the dosing cycle. One guideline recommends scheduling surgery about one week after the next dose of secukinumab would have been due.
JAK inhibitors (tofacitinib, upadacitinib, baricitinib) are not technically biologics but are often prescribed for the same conditions. They clear the body much faster because they’re small-molecule pills rather than injected proteins. The recommendation is to stop them about one week before surgery.
Does the Type of Surgery Matter?
Yes. The hold recommendations above are designed for major procedures, particularly joint replacement and abdominal surgery, where large incisions and hardware create significant infection risk. For minor procedures like skin biopsies or simple dental extractions, many clinicians take a less aggressive approach. Some dental guidelines still recommend holding biologics for four to five half-lives before oral surgery involving extraction or periodontal work, but routine cleanings and fillings generally don’t require stopping treatment.
Studies in Crohn’s disease patients who continued infliximab before abdominal surgery found no significant increase in postoperative complications compared to controls. A large meta-analysis of over 8,000 ulcerative colitis patients found no meaningful association between preoperative biologic use and postoperative infection. The pooled odds of infection were essentially the same whether patients had recent biologic exposure or not. Interestingly, the time between the last biologic dose and surgery didn’t influence infection rates either. These findings suggest the infection risk from biologics around surgery may be smaller than originally feared, at least for some procedures.
The Flare Risk of Stopping
Holding biologics before surgery is not without consequences. In a study of 58 rheumatoid arthritis patients undergoing hip or knee replacement, 60% experienced a disease flare within six weeks of surgery. After adjusting for other factors, patients who had discontinued biologics were nearly 15 times more likely to flare than those who hadn’t. Obesity was the other major risk factor, increasing flare odds sixfold.
A flare during surgical recovery is more than just uncomfortable. Joint inflammation, pain, and stiffness can interfere with physical therapy and rehabilitation, potentially compromising surgical outcomes. This tradeoff between infection prevention and disease control is why the trend in perioperative management is shifting toward more individualized decisions. Rather than applying blanket rules, rheumatologists and surgeons are increasingly making shared decisions based on the specific patient’s disease activity, the type of procedure, and the biologic being used.
When to Restart After Surgery
Current guidelines recommend restarting biologics once the surgical wound shows adequate healing, there’s no sign of infection, and sutures or staples have been removed. For most joint replacements, this typically means resuming treatment about 14 days after surgery, though your surgical team may adjust based on how healing progresses. The goal is to restart as quickly as safely possible to reduce flare risk and avoid prolonged time off therapy.
Methotrexate, which many biologic users also take, is generally continued through surgery without interruption. Glucocorticoids like prednisone are also typically maintained at the patient’s usual dose rather than increased, a change from older practice that called for “stress dose” steroids around surgery.