Infliximab Discontinuation and Postoperative Infection Risk

Study examined patients who received infliximab for rheumatologic conditions and the incidence of postoperative infections.

Administering infliximab less than 4 weeks prior to hip or knee joint replacement surgery does not increase the risk for postoperative infection in patients with rheumatologic diseases, according to a study published in Arthritis Care & Research.

Tumor necrosis factor (TNF) inhibitors are associated with risk for serious infection. Concerns about an increased risk for postoperative infections in patients treated with TNF inhibitors have led professional society guidelines to recommend interrupting TNF-inhibitor therapy before surgery. However, data on the effects of stopping TNF inhibitors preoperatively are limited, and recommendations on the timing for holding therapy vary. In addition, interrupting TNF-inhibitor therapy may lead to disease flares and subsequent glucocorticoid use, which may increase infection risk.

A team of researchers led by Michael D. George, MD, MSCE, from the University of Pennsylvania investigated whether stopping the TNF inhibitor infliximab before surgery affected the risk of postoperative infection in older patients undergoing elective knee or hip arthroplasty.

High Yield Data Summary

  • Stopping infliximab <4 weeks or 4 to 8 weeks prior to surgery resulted in similar rates of serious infection at 30 days and prosthetic joint infection at 1 year compared with stopping at 8 to 12 weeks. 

Data from 3867 patients who underwent 4288 surgeries were analyzed in this retrospective cohort study. 

Patients received infliximab for rheumatologic conditions, including rheumatoid arthritis, inflammatory bowel disease, psoriasis, psoriatic arthritis, and ankylosing spondylitis.

Patients were grouped by infliximab stop timing: <4 weeks, 4 to 8 weeks, and 8 to 12 weeks before surgery.

Infliximab stop timing <4 weeks and 4 to 8 weeks prior to surgery were associated with similar rates of serious infection at 30 days and prosthetic joint infection at 1 year compared with infliximab stop timing 8 to 12 weeks.

In contrast, administering glucocorticoids at dosages higher than 10 mg/d more than doubled the risk for 30-day infection (odds ratio, OR 2.11) and prosthetic joint infection (hazard ratio, 2.70).

“Stopping infliximab, and likely other TNF inhibitors, for long periods of time before surgery is probably not helpful,” Dr George told Rheumatology Advisor. “If stopping TNF inhibitors leads to disease flares and increased use of glucocorticoids, this in fact might lead to more infections.”

Summary and Clinical Applicability

Due to concerns about postoperative infection, TNF-inhibitor therapy is commonly interrupted before surgery, for up to 12 weeks at a time. Researchers examined the risk of postoperative infection in patients with rheumatic conditions undergoing elective hip and knee arthroplasty in whom infliximab therapy was held before surgery. 

The main finding of this study was that infection rates at 30 days and prosthetic joint infection rates at 1 year after surgery were similar with infliximab stop timing <4 weeks preoperatively vs 8 to 12 weeks before surgery. “Holding infliximab for long periods of time before surgery does not seem to decrease the risk of postoperative infection,” Dr George said.

“However, higher doses of glucocorticoids are associated with substantial increases in the risk of infection,” he added. “All attempts should be made to have patients on as little prednisone as possible before surgery, especially avoiding higher doses above 10 mg per day.”

Limitations and Disclosures

  • The study examined stop timing of infliximab, so the results may not be generalizable to other TNF inhibitors, especially those with a different mechanism of action 

  • Relying on ICD-9 diagnosis codes to measure outcomes may have resulted in misclassification of some outcomes

Dr Yun has received research grants from Amgen. Dr Curtis has received research grants and consulting fees from Bristol-Myers Squibb, Janssen, Pfizer, Amgen, UCB, and Myriad Genetics.

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George MD, Baker JF, Yenchih Hsu J, et al. Perioperative timing of infliximab and the risk of serious infection after elective hip and knee arthroplasty [published online January 27, 2017]. Arthritis Care Res (Hoboken). doi:10.1002/acr.23209

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