What is your approach when surgeons want to stop hydroxychloroquine prior to surgery?

I would absolutely say "do NOT stop HCQ."

This is most likely a case of the surgical team mistaking HCQ for an immunosuppressant drug rather than an immunomodulatory drug. I would write a tactful "Rheumatologic Perioperative Recommendations" note where I would specifically state not to stop it and that a bad flare of lupus could be one of the worst things to happen perioperatively and that HCQ does not suppress the immune system, nor increases infection risks, nor prolongs wound healing. A phone call to the NS may be in order as well and providing a copy of the ACR perioperative management guidelines. (Goodman et al., PMID 35718887 - PDF)

I have a stack of the perioperative management guidelines in my office, have shared this with patients, often giving two copies for them to share with their surgeon. Hydroxychloroquine remains in the body for several months; holding it for a week has no pharmacologic benefit. Similarly leflunomide, because of its being resorbed via enterohepatic activity; stopping a medication for seven days prior to surgery that requires two weeks of cholestyramine to achieve medication washout has no logical benefit whatsoever.

I have tried to provide evidence based medicine management of rheumatologic patients; despite my providing such evidence to the surgeons, they are too often hard to reach. Thank goodness that ACR and the surgical partners they work...

The issue of the benefits versus the risks of interrupting hydroxychloroquine in lupus patients before surgery has never been formally studied. However, I agree with the previous answers indicating no need to discontinue because of a mistaken understanding that the antimalarial is immunosuppressive as opposed to anti-inflammatory. No reason to believe that hydroxychloroquine increases the perioperative risk for infection. The issue of postoperative bleeding is interesting. In 1977, Dr. Charnley reported that the incidence of postoperative DVT was reduced by the use of hydroxychloroquine. In vitro studies establish a weak platelet inhibitory effect, and cohort studies demonstrate less thrombosis in SLE patients on the drug. This suggests the...

While there is no rationale with regard to immunosuppression considerations to hold HCQ perioperatively, known effects of HCQ on platelet aggregation might be a consideration. While these effects were demonstrated in studies performed ex-vivo with known platelet aggregation agonists, there are also several studies suggesting fewer thrombotic events in patients given HCQ in pro-thrombotic settings. As such, for patients undergoing surgical procedures where bleeding complications could be catastrophic (i.e. neurosurgical procedures), it may be prudent to hold HCQ peri-operatively. How long dosing should be held pre-operatively to avoid potential bleeding complications is not really established, but as noted by previous responders the eliminat...

As a rheumatologist, you are the expert on HCQ, not the neurosurgeon.

This physician and their medical team need education that HCQ is not immunosuppressive and should not be stopped for surgery because of that concern.