Biologics In RA

For patients with rheumatoid arthritis (RA) undergoing arthroplasty, the risk for postoperative infection is similar across biologics but is increased with glucocorticoid use, according to a study published online in the Annals of Internal Medicine.

Michael D. George, M.D., from the University of Pennsylvania Perelman School of Medicine in Philadelphia; and colleagues compared the risk for postoperative infection; among biologics and the risk associated with glucocorticoids in patients with RA undergoing arthroplasty. Data was include for 9,911 adults with RA treat with biologics; who underwent 10,923 elective inpatient total knee or hip arthroplasty procedures.

But propensity-adjusted analyses using inverse probability weights evaluated comparative risks for hospitalized infection; within 30 days and prosthetic joint infection (PJI) within 1 year after surgery; but between biologics or with different dosages of glucocorticoids. Secondary analyses evaluated non–urinary tract hospitalized infections and 30-day re-admissions.

Hospitalized infection

But the researchers found that patients who received different biologics had similar outcomes. For hospitalized infection, the predicted risk from propensity-weighted models ranged from 6.87% with adalimumab; but to 8.90% with rituximab compared with 8.16% with abatacept. But the one-year cumulative incidence of prosthetic joint infection (PJI), the predicted incidence ranged; from 0.35% with rituximab to 3.67% with tocilizumab compared with 2.14% with abatacept.

But for all outcomes, glucocorticoids correlated with a dose-dependent increase in postoperative risk. Compared with no use, use of more than 10 mg of glucocorticoids; per day resulted in a predicted risk for hospitalized infection of 13.25 versus 6.78%; and a predicted one-year cumulative incidence of PJI of 3.83 versus 2.09%. “Minimizing glucocorticoid exposure before surgery should be a primary focus of perioperative medication management”; the authors write. Several authors disclosed financial ties to the pharmaceutical industry.

Risk for hospitalized infection

Among 9911 patients treat with biologics, 10 923 surgical procedures were identify. Outcomes were similar in patients who received different biologics. But compared with an 8.16% risk for hospitalized infection with abatacept, predicted risk from propensity-weighted models; ranged from 6.87% (95% CI, 5.30% to 8.90%) with adalimumab to 8.90% (CI, 5.70% to 13.52%) with rituximab.

Compared with a 2.14% 1-year cumulative incidence of PJI with abatacept, predicted incidence ranged from 0.35% (CI, 0.11% to 1.12%) with rituximab to 3.67% (CI, 1.69% to 7.88%) with tocilizumab. Glucocorticoids were associated with a dose-dependent increase in postoperative risk for all outcomes. Propensity-weighted models showed that use of more than 10 mg of glucocorticoids per day (vs. no glucocorticoid use) resulted in a predicted risk for hospitalized infection of 13.25% (CI, 9.72% to 17.81%) (vs. 6.78%) and a predicted 1-year cumulative incidence of PJI of 3.83% (CI, 2.13% to 6.87%) (vs. 2.09%).

Residual confounding is possible, and sample sizes for rituximab and tocilizumab were small. Risks for hospitalized infection, PJI, and readmission after arthroplasty were similar across biologics. In contrast, glucocorticoid use, especially with dosages above 10 mg/d, was associated with greater risk for adverse outcomes.