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Infliximab Given Within 4 Weeks Prior to Arthroplasty Showed No Increased Infection Rate
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Researchers found patients who were administered infliximab within 4 weeks before knee or hip arthroplasty had no increased risk for infection compared with patients who were given the therapy within 8 weeks to 12 weeks before surgery, according to results of a recently published study. However, there was an increased risk for infection with glucocorticoid use.
Michael D. George, MD, MSCE, in the Division of Rheumatology at the University of Pennsylvania, and colleagues assessed 4,288 Medicare patients with rheumatoid arthritis (RA), inflammatory bowel disease, psoriasis, psoriatic arthritis or ankylosing spondylitis treated with infliximab within 6 months of elective knee or hip arthroplasty between 2007 and 2013. Researchers examined the association between hospitalized infection within 30 days or prosthetic joint infection (PJI) within 1 year and the time between most recent infliximab infusion and surgery.
Researchers found hospitalized infection occurred after 6.3% of surgeries. They found no increased risk for infection between a most recent infusion within 4 weeks of surgery compared with 8 weeks to 12 weeks before surgery. The PJI rate was 2.9 per 100 person-years and was not increased in patients with a most recent infusion within 4 weeks. However, glucocorticoid use of greater than 10 mg per day was associated with an increased risk for 30-day infection (odds ratio = 2.11) and PJI (hazard ratio = 2.7). In addition, researchers identified elderly age, comorbidities, revision surgery and previous hospitalized infection as risk factors for infection. – by Will Offit
Disclosures: George reports no relevant financial disclosures. Please see the full study for a list of all other relevant financial disclosures.
Perspective
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Cassandra M. Calabrese, DO
Up to 30% of patients with RA will eventually undergo joint reconstructive surgery, yet we have limited data to guide the perioperative management of disease-modifying antirheumatic drugs (DMARDs) and biologics. This decision is often surgeon-dependent. Historically, patients with RA have worse outcomes after joint replacement, but this was largely due to poor disease control prior to surgery.
This study shows that patients receiving infliximab within 2 weeks to 8 weeks prior to surgery were not more likely to develop infection compared to patients who received infliximab 8 weeks to12 weeks preop. As expected, average prednisone dose greater than 10 mg in the month prior to surgery was associated with post-op infection.
A limitation of this study is the lack of data on disease activity at the time of surgery, as this can also contribute to poor surgical outcomes. Overall, these results may help us to feel more comfortable holding tumor necrosis factor inhibitors closer to the time of surgery.
Of note, currently in the works are the first joint recommendations from the ACR and the American Association of Hip and Knee Surgeons for the perioperative management of rheumatic disease medications in total hip and knee replacements. The recommendations are expected to be out later this year.
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