Preparing for Surgery With Lupus: A Rheumatologist’s Checklist
posted in All on November 1, 2026 by
Surgery presents unique challenges for lupus patients, who are at higher risk of infections and other complications. The most important thing I tell my patients is this: surgeons are rarely familiar with lupus medications and conditions such as Sjögren’s disease, so if you have a rheumatologist, they should have the final word.
NOTE: Johns Hopkins University Press, publisher of The Lupus Encyclopedia, is a nonprofit publisher. If you purchase JHUP books, like The Lupus Encyclopedia, you support projects like Project MUSE.
Most surgery is elective rather than emergency, which means you usually have adequate time to prepare properly. This article walks through what to do with that time.
A note on scope: every surgery is different, with different preparation and recovery requirements. This article gives the general principles that apply in lupus. It does not replace the specific advice of your surgical team.
Who needs to be involved
Ask your surgeon whether you need additional recommendations from other doctors. In most cases, you should have a surgical evaluation and medical advice from both your primary care provider and your rheumatologist.
If your lupus affects internal organs, you may also need input from the relevant specialist:
- Kidneys: your nephrologist
- Lungs: your pulmonologist
- Heart: your cardiologist
- Liver: your gastroenterologist
If you receive conflicting recommendations from your surgeon about any medication, ask the prescribing physician to speak to the surgeon directly. Written or verbal communication between them matters, and it is reasonable to ask for it.
What to bring to your first surgical appointment
Preparation begins at the very first appointment. Take the following with you:
- Your medical records
- A list of all prescription drugs with doses, how often you take them, and what each is for
- A list of all over-the-counter drugs, including vitamins and herbal supplements
- A list of all your medical problems, including which lupus problems you have (such as lupus nephritis, interstitial lung disease, or lupus hepatitis)
- A list of all past surgical procedures
- A list of all drug allergies and intolerances, including sulfonamide (sulfa) antibiotics
- Names and phone numbers of your doctors
- Names and phone numbers of your emergency contacts
- Surgical preparation instructions from your rheumatologist, primary care provider, and specialists
- Advance directives and power-of-attorney papers, if you have them
Which medications to stop, and when
This is where most of the risk sits, and where lupus patients differ most from other surgical patients.
These recommendations generally follow the 2022 American College of Rheumatology surgical guidelines, which were written for hip and knee replacement surgery. They may not apply to some other operations, particularly heart and vascular surgery.
If you take several medications, keeping track of the stop and restart dates becomes genuinely difficult. Ask the doctor who prescribed each drug when to stop it and when to resume it, then write those dates on a calendar alongside your surgery date. Some dates may need to change later. If your wound does not heal well or an infection develops, you may need to delay restarting immunosuppressants.
One practical tip: hospitals do not stock every medication. Bring your own and ask your surgeon to write an order permitting you to take your own medicines for anything the hospital does not carry.
Steroids: do not stop them
You usually should not stop steroids for surgery.
Your adrenal glands normally produce extra steroid during a stressful event such as an operation, and that surge is what allows your body to respond appropriately. If you have taken steroids at high doses or for an extended period, your adrenal glands may no longer do this properly. In that case you may need extra steroid around the surgery, which doctors call a stress dose.
Ask your rheumatologist whether you need stress doses, then tell your surgeon and anesthesiologist.
There is a competing consideration. Steroids interfere with wound healing, and higher doses are associated with poor healing at the surgical site, which raises infection risk. So your doctors will want you on the lowest possible dose before and after surgery, aside from any stress doses you need.
If you have only been taking steroids briefly, you may be able to stop them for surgery.
Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin
Most NSAIDs, including aspirin, prevent platelets from clotting properly, which means excess bleeding during surgery. When to stop them depends on the specific drug and on the operation.
| Drug | When to stop before major surgery |
|---|---|
| Aspirin | 7 to 10 days |
| Piroxicam | 11 days |
| Meloxicam (if stopped for blood pressure or kidney reasons) | At least 5 days |
| Most other NSAIDs | 3 to 4 days |
| Ibuprofen and ketoprofen (immediate-release) | 24 hours |
| Salsalate, diflunisal, celecoxib | 3 days is usually enough |
Some surgeries carry so little bleeding risk that NSAIDs do not need to be stopped at all. Cataract surgery, minor dental work, and skin surgery generally fall into this group.
Others carry such high bleeding risk that NSAIDs are always stopped. These include operations on the brain, around the spinal cord, inside the middle ear, and at the back of the eye.
An important exception on aspirin. Some patients take aspirin to prevent heart attacks and strokes, and their risk of a cardiovascular event may be higher than their risk of surgical bleeding. This includes people with stents in the arteries of the heart, arms, or legs, where stopping aspirin could allow a clot to block the stent. If you have significant heart, blood vessel, or brain problems, ask your cardiologist, vascular surgeon, or neurologist before stopping aspirin.
Note also that non-acetylated salicylates and COX-2 inhibitors such as salsalate, diflunisal, celecoxib, and meloxicam do not thin the blood. They may still need stopping, but for a different reason: all NSAIDs other than low-dose aspirin can raise blood pressure or reduce blood flow to the kidneys.
Once bleeding risk has passed, NSAIDs can often be restarted as soon as 24 hours after surgery. If you take them for pain, restart them as soon as you are allowed, so your usual non-surgical pain does not come flooding back.
Other blood thinners
Some lupus patients take warfarin, clopidogrel, enoxaparin, fondaparinux, dabigatran, rivaroxaban, apixaban, or dalteparin.
Whether and when to stop these is genuinely complex and depends on why you are taking them in the first place. Ask all your doctors, especially your hematologist and cardiologist, if you have them.
Immunosuppressants: a real trade-off
These drugs increase infection risk, but they keep your lupus inflammation under control. Stopping them could cause a flare.
Here is the point I want patients to understand: the consequences of a lupus flare are often worse than the risks of staying on the immunosuppressant. A flare itself increases infection risk through immune system abnormalities. It can seriously interfere with rehabilitation. And if steroids are then needed to treat the flare, that raises infection risk more than the other immunosuppressants would have and interferes with wound healing on top of it.
So the decision has to be made carefully, based on how severe your lupus is, how likely you are to flare, and which drugs you take. It would be reasonable to stop immunosuppressants in someone with mild lupus and a low flare risk, while continuing them in someone with severe disease.
Three specific points:
- Methotrexate does not appear to increase surgical infections, so you may not need to stop it. The exception is chronic kidney disease, where dangerous methotrexate levels could build up if kidney function drops during or after surgery
- Leflunomide is also listed by the ACR as a drug that does not have to be stopped
- Do not stop hydroxychloroquine. It is not an immunosuppressant
Pain medications
If you take pain medication daily, you may need to continue it through surgery or be switched to a surgery-safe alternative. Stopping some of these, opioids in particular, can cause withdrawal symptoms and severe pain. Ask your prescribing doctor rather than assuming.
Sjögren’s medications
Cevimeline and pilocarpine help increase saliva and tear production. Because they can constrict airway passages, lower blood pressure and heart rate, and cause urination problems, some experts recommend avoiding them around surgery in patients at high risk of those problems.
Both leave the system quickly, so simply not taking them the day before surgery is sufficient.
Estrogen and related hormones
Drugs containing estrogen and related hormones increase blood clot risk, so it is generally best to stop them before surgery. Ask your prescribing doctor and your surgeon.
For transgender women taking higher doses of estrogen, some experts recommend reducing the dose a few weeks before surgery, stopping before the operation, then waiting a week afterwards before restarting at a low dose, with full doses resumed after a couple of weeks.
Raloxifene, used to prevent and treat osteoporosis, may be fine to continue for surgeries with low clot risk. For high-risk surgeries it should be stopped at least 7 days beforehand and restarted once the clot risk has passed.
Supplements and herbal products: stop everything
This is the section people most often overlook.
- Increase bleeding: turmeric, curcumin, fish oil, omega-3 fatty acids, vitamin E, garlic, ginkgo, ginseng
- Dangerous interactions with anesthesia drugs: kava, valerian, St. John’s wort
- Heart problems: ephedra, also sold as ma huang
- Low blood sugar: ginseng, and turmeric or curcumin
Some of these take a long time to clear from your system. The simplest safe approach is to stop all supplements and herbal products at least one week before surgery.
If you have Raynaud’s
Hospitals (especially operating rooms) are colder than normal. For someone with Raynaud’s, that means reduced blood flow to the fingers and toes, which can become painful or develop open sores.
Tell your anesthesiologist and nurses about your Raynaud’s in advance. They can raise the operating room temperature ahead of time. Ask for extra blankets, socks, a hat, and coverings for your hands and feet in both the operating room and recovery.
If you have Sjögren’s
Surgery can make Sjögren’s dryness considerably worse. Hospital and operating room humidity is very low, the medications used for pain, anesthesia, and skin cleansing are drying, and tubes placed in the nose and throat irritate already dry tissue.
The best protection is preparation:
- Ask your rheumatologist to include Sjögren’s instructions in their surgical recommendations, rather than relying on you to explain it on the day
- Bring all your eye, mouth, ear, nose, and skin moisturizers to the hospital. Use them immediately before surgery if allowed, and ask recovery room nurses to use them straight afterward
- Ask the anesthesiologist to humidify your oxygen if oxygen is needed
- Ask them to use a moisturizing gel in your eyes while they are closed during surgery, to protect the cornea
- Remind the surgical team that tubes going into the nose or throat may need extra lubrication
- Bring a moisturizing nose spray or gel even if you do not normally use one, and bring a lip moisturizer, because you will need it
You will be told not to eat or drink before surgery. This usually does not include artificial saliva, so if you use it, you can generally continue. Check the specific brand with your surgeon and anesthesiologist.
One further risk: antibiotics during and after surgery increase the chance of Candida infections, and Sjögren’s patients are already at higher risk. Watch for soreness and redness of the tongue or corners of the mouth, a sore throat, a white coating inside the mouth, or vaginal discharge. Eating probiotic-rich foods such as live-culture yogurt before and after surgery may help, and you can ask your doctors about antifungal medication.
The preparation checklist
- Gather everything on the list above to take to your surgeon and anesthesiologist
- Have each of your doctors give you stop and restart dates for every medication, and put them on a calendar
- See all the specialists who manage your organ involvement, such as your lung, kidney, or heart doctor
- Prepare written information about your Raynaud’s for the surgical team
- Prepare written information about your Sjögren’s for the surgical team
- Bring all your own medications to the hospital in case they are not stocked
Frequently asked questions
Should I stop my lupus medications before surgery?
Some, but not all, and never on your own. Do not stop steroids or hydroxychloroquine. Methotrexate and leflunomide usually do not need stopping. Whether to hold other immunosuppressants depends on how severe your lupus is and how likely you are to flare. Your doctor should make every decision.
Do I need stress dose steroids for surgery?
Possibly. If you have taken steroids at high doses or for a long period, your adrenal glands may not produce the extra steroid your body normally makes during surgery. Ask your rheumatologist, then tell your surgeon and anesthesiologist what was decided.
When should I stop aspirin before surgery?
Usually 7 to 10 days before major surgery, though this does not apply to everyone. If you take aspirin to prevent a heart attack or stroke, especially if you have stents, stopping it may be more dangerous than the bleeding risk. Ask your cardiologist first.
Can surgery cause a lupus flare?
It can, which is why immunosuppressants are not automatically stopped. A flare can increase infection risk, interfere with your rehabilitation, and require steroids that then slow wound healing further.
Do I need to stop my supplements before surgery?
Yes. Several common ones increase bleeding, including turmeric, fish oil, vitamin E, garlic, ginkgo, and ginseng, and others interact dangerously with anesthesia. Because some take a long time to clear, stop all supplements and herbal products at least one week before surgery.
What should I tell the surgical team about Raynaud's?
Tell them before the day, so the operating room can be warmed in advance, and ask for extra blankets, socks, a hat, and hand and foot coverings in both the operating and recovery rooms.
For more information
For more in-depth information on Preparing for Surgery With Lupus: A Rheumatologist’s Checklist:
Read more in The Lupus Encyclopedia, edition 2
Look up your symptoms, conditions, and medications in the Index of The Lupus Encyclopedia
If you enjoy the information from The Lupus Encyclopedia, please click the “SUPPORT” button at the top of the page to learn how you can help.
What are your comments and opinions?
If you have lupus, what has your experience been? What do you recommend for other patients?
Do you have any questions to ask Dr. Thomas?
Please click on “Leave a Comment” above to comment.
Please support “The Lupus Encyclopedia” blog post page
Click on “SUPPORT” at the top of the page to learn how you can support “The Lupus Encyclopedia“
This article includes contributions from
No comment yet, add your voice below!
Leave a comment