Interruption of biologic therapy is not required before major surgery in patients with rheumatoid arthritis (RA), but physicians should consider limiting glucocorticoid use as a part of perioperative management, according to research results published in the Annals of the Rheumatic Diseases.
Researchers aimed to evaluate the associations between the use of biologic therapies and adverse outcomes in patients with RA who underwent common major surgical procedures, excluding arthroplasty but including hip fracture, abdominopelvic, and cardiac surgeries. Investigators also sought to evaluate the associations between glucocorticoid use and adverse outcomes.
Medicare claims data from 2006 to 2015 were used to evaluate adults aged ≥18 years with RA who underwent ≥1 of the prespecified surgeries between 2007 and 2015. Patients were classified in mutually exclusive groups based on type of medication therapy — methotrexate prescription fill <8 weeks before surgery with no biologics or targeted synthetic disease-modifying antirheumatic drugs (tsDMARDs) <6 months before surgery; tumor necrosis factor inhibitors (TNFi) biologic prescription or infusion <8 weeks before surgery with or without methotrexate; or non-TNFi biologic prescription or infusion or tsDMARD prescription fill <8 weeks before surgery with or without methotrexate — to assess the associations between immunosuppression use and postoperative outcomes. Associations between glucocorticoid use 90 days before surgery (prednisone, prednisolone, and methylprednisolone) and postoperative outcomes were also examined.
Investigators identified 10,777 surgeries in 10,483 patients (mean age, 72 years; 80% women). Overall, 57% of patients used methotrexate without a biologic or tsDMARD, 33% used a TNFi, and 10% used a non-TNFi biologic or tsDMARD. Patients underwent hip fracture repair (33%), abdominopelvic surgery (47%), and cardiac surgery (20%).
Within 90 days of surgery, 5.4% of patients died and 12.8% were readmitted to the hospital within 30 days of discharge. Outcomes “varied substantially” by surgery type, but were highest after nonelective colectomy or valve surgery, and lowest after hysterectomy. Common reasons for hospital readmission included complications, septicemia, and congestive heart failure.
No significant difference was noted in 90-day mortality among patients receiving TNFi or non-TNFi biologics or tsDMARDs (adjusted odds ratio [aOR], 0.83 and 0.78, respectively) compared with patients receiving methotrexate without a biologic or tsDMARD. A 30-day readmission risk was somewhat lower in the TNFi group and similar in the non-TNFi biologic/tsDMARD group (aOR, 0.86 and 1.02, respectively). Among patients receiving glucocorticoid therapy, unadjusted rates of 90-day mortality and 30-day readmission were higher among patients receiving higher doses. A significantly higher risk for 90-day mortality and 30-day hospital readmission was noted in patients receiving an average of 5 to 10 mg per day (aOR, 1.41 and 1.26 for mortality and readmission, respectively) or >10 mg per day of glucocorticoid therapy (aOR, 1.64 and 1.60 for mortality and readmission, respectively).
There were no significant differences in risk for secondary outcomes (pneumonia requiring hospitalization or wound complications within 30 days of surgery) among patients in the TNFi or non-TNFi biologic/tsDMARD groups compared with patients receiving methotrexate therapy. However, higher-dose glucocorticoids were associated with a greater risk for wound complications (aOR, 1.72 for 5-10 mg/d; aOR, 1.68 for >10 mg/d).
Study limitations included those inherent in observational studies, potentially missing or misclassified claims data, and an inability to examine morbidity or minor complications that did not lead to hospitalization. An additional limitation was the exclusion of patients who experienced recent changes in therapy who may have had the highest disease activity.
“Neither use of biologics nor biologic timing before surgery were associated with increased mortality or readmission after hip fracture, abdominopelvic, or cardiac surgery,” the researchers concluded. “Higher dose glucocorticoids were associated with adverse outcomes after these surgeries, suggesting that minimizing glucocorticoids should be a focus of perioperative medicine.”
Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
George MD, Baker JF, Winthrow KL, et al. Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery [published online March 24, 2020]. Ann Rheum Dis. doi:10.1136/annrheumdis-2019-216802