Stopping biologic disease-modifying antirheumatic drugs (bDMARDs) for patients with rheumatoid arthritis (RA); before they undergo hip or knee replacement might increase postoperative infection; risk if it leads to increased use of glucocorticoids (GCs) to control disease flares, a study suggests. Guidelines advise stopping bDMARDs before patients with RA undergo hip or knee replacement; but the investigators say more research is need to determine whether stopping bDMARDs actually improves outcomes.
The authors write, “Patients with RA who are treat with various bDMARDs before total hip or knee arthroplasty; have similar rates of postoperative infection and readmission. Glucocorticoid use is strongly associate; but with postoperative infection risk even at modest doses. Minimizing glucocorticoid exposure before surgery should be a primary focus; of perioperative medication management.” The study, by Michael D. George, MD, University of Pennsylvania Perelman School of Medicine, Philadelphia; and colleagues, was published online May 20 in the Annals of Internal Medicine.
Hospitalized for infection
The use of even modest doses of GC before surgery (5 – 10 mg/day), in comparison with no GC use; was associate with a 30% higher postoperative risk that RA patients would be hospitalize for infection; within 30 days after joint replacement or for prosthetic joint infection (PJI) within 1 year after surgery. GC doses >10mg/day doubled the postoperative risk. There were no major differences in postoperative risk; associated with use of various biologic therapies.
In a linked editorial, Bheeshma Ravi, MD, PhD, and Gillian Hawker, MD; from the University of Toronto, Ontario, Canada, note that the analysis could not determine whether biologic therapy per se increased risk; because the study did not include a group of patients who received nonbiologic therapy and; because the authors could not differentiate patients for whom biologics; was before surgery from those who continue taking biologics.
Knee or hip arthroplasty
“An obvious concern about withholding biologic therapies in the perioperative period is that this may result in RA flare; necessitating an increase in glucocorticoid dosage. Given the strong relationship between glucocorticoid therapy and risk for postoperative infection found in this study.
Additional research is warranted to determine the management approach that is associated; with lowest risk for serious postoperative infection,” Ravi and Hawker write. George and colleagues used data from the Medicare and Truven MarketScan administrative databases to compare postoperative infection risks; but in nearly 10,000 patients with RA following primary or revision total knee or hip arthroplasty.
Patients had been treated with abatacept (Orencia, Bristol-Myers Squibb), adalimumab (multiple brands), etanercept (multiple brands), infliximab (multiple brands), rituximab (multiple brands), or tocilizumab (Actemra, Genentech) before surgery. In addition to the bDMARD, 43.0% of patients had received GCs, and 45.6% had received methotrexate within 90 days before surgery. The median age of the patients was 65.1 years, 83.0% of the patients were women, and 89.5% of the procedures were primary. Only 3.9% of patients had received GC doses >10 mg/day (median, 12.1 mg/day).