DMARD use not linked to postsurgical complications in people with RA
medwireNews: Individuals with rheumatoid arthritis (RA) are at no more risk for postsurgical complications if they have used a biologic or targeted synthetic (ts)DMARD in the weeks preceding surgery than if they had used methotrexate, US research shows.
By contrast, even low-dose glucocorticoid use was associated with an increased risk for adverse outcomes, suggesting that “[p]rolonged interruptions in biologics before major surgery [are] likely not required, but minimising glucocorticoids before surgery should be a focus of perioperative management,” Michael George (University of Pennsylvania, Philadelphia, USA) and colleagues remark.
Using Medicare data, George and co-investigators identified 10,483 patients (mean age 72 years, 80% women) with RA who underwent 10,777 surgeries between 2006 and 2015. These included 3585 hip fracture repairs, 5025 abdominopelvic surgeries (cholecystectomy, hysterectomy, hernia, appendectomy, or colectomy), and 2167 cardiac surgeries (coronary artery bypass graft or mitral/aortic valve surgery).
Over half (57%) of the of the patients received methotrexate without a biologic or tsDMARD during the 8 weeks before surgery, 33% received a tumor necrosis factor (TNF) inhibitor (most commonly infliximab), and 10% received a non-TNF inhibitor biologic or tsDMARD (most commonly abatacept). Tofacitinib was the only tsDMARD used in the study, with 0.3% of patients taking this Janus kinase inhibitor.
The researchers report that, overall, the hospital readmission rate was 12.8% within 30 days of discharge, while the mortality rate was 5.4% within 90 days of surgery.
After adjustment for potential confounders, George and team found that individuals receiving a TNF inhibitor or a non-TNF inhibitor biologic or tsDMARD were no more likely to die within 90 days of surgery than those receiving methotrexate.
People receiving a non-TNF inhibitor biologic or tsDMARD also had a similar risk for 30-day readmission to those receiving methotrexate, but the investigators say the risk was “somewhat lower” among the patients treated with a TNF inhibitor versus methotrexate, with a significant 14% reduced risk.
In addition, the researchers analyzed the data according to glucocorticoid use and found that the risk for readmission and mortality increased with increasing dose.
Specifically, people who used glucocorticoids at a dose of 5–10 mg/day had a significant 26% increased risk for readmission within 30 days and 41% increased risk for death within 90 days relative to nonusers. The risks were a significant 60% and 64% higher, respectively, among people using glucocorticoids at a dose of more than 10 mg/day.
The researchers conclude in the Annals of the Rheumatic Diseases that their findings “suggest that necessary non-elective surgeries need not be delayed in patients receiving biological therapy, since delaying these surgeries has its own consequences.”
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