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Low Risk with Immunosuppression at Surgery

Apr 13, 2020 1:07 pm

The Annals of Rheumatic Disease reports that rheumatoid arthritis patients (RA) on biologic therapies do not have a greater risk of postoperative infection after hip fracture, abdominopelvic or cardiac surgery compared (compared with those on methotrexate alone) and that glucocorticoids were associated with a dose-dependent increase risk for postoperative infections.

These results differ from prior studies that have typically examined risk of immunosuppression in patients undergoing elective arthroplasty. Those studies are clear in showing the post operative risks to be augmented by disease activity, comorbidities and steroids. Conventional disease-modifying antirheumatic drugs (eg, MTX) have not been associated with an increased postoperative risk. But the risk with biological therapies remains uncertain, as studies have been inconsistent or negative for risk. 

This retrospective cohort analysis of Medicare data 2006–2015 analyzed RA patients undergoing hip fracture repair, abdominopelvic surgery (cholecystectomy, hysterectomy, hernia, appendectomy, colectomy) or cardiac surgery (coronary artery bypass graft, mitral/aortic valve). They examined 90-day mortality and 30-day readmission rates in those on MTX or a targeted synthetic disease-modifying antirheumatic drug (tsDMARD), a tumour necrosis factor inhibitor (TNFi) or a non-TNFi biologic/tsDMARD within 8 weeks of surgery.

Among 10777 eligible surgeries: 3585 hip fracture, 5025 abdominopelvic and 2167 cardiac surgeries.

The following treatment cohorts were compared to MTX alone and showed no increase in the risk of 90-day mortality or 30-day readmission: 

TNF Inhibitor

  • mortality adjusted OR (aOR) =  0.83 (0.67 to 1.02)
  • readmission aOR 0.86 (0.75 to 0.993))

non-TNFi biologic/tsDMARD

  • mortality aOR 0.78 (0.49 to 1.22)
  • readmission aOR 1.02 (0.78 to 1.33)).

Yet the risk of mortality and readmission was higher with prednisone 5–10 mg/day (mortality aOR 1.41 (1.08 to 1.82), readmission aOR 1.26 (1.05 to 1.52)) or >10 mg/day (mortality aOR 1.64 (1.02 to 2.64), readmission aOR 1.60 (1.15 to 2.24)) versus no glucocorticoids.

Recent biologic or tsDMARD use was not associated with a greater risk of mortality or readmission after hip fracture, abdominopelvic or cardiac surgery.

The author has no conflicts of interest to disclose related to this subject

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