Glucocorticoids, Not Biologics, Increase Adverse Outcome Risk After Major Surgery in RA
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Recent use of biologics or targeted synthetic DMARDs is not associated with an increased risk for mortality or readmission following hip fracture, abdominopelvic or cardiac surgery, compared with methotrexate, according to data published in the Annals of the Rheumatic Diseases.
However, the researchers determined that even low-dose glucocorticoid use was linked to a greater risk for postsurgical adverse outcomes.
“Immunosuppression is a big concern in patients who are undergoing surgery because of concerns that immunosuppression could lead to post-operative infections or impaired wound healing,” Michael D. George, MD, MSCE, of the University of Pennsylvania, told Healio Rheumatology. “Most data about the impact of immunosuppression on outcomes are from studies of joint replacement.”
“This study evaluates risks associated with biologic use and glucocorticoid use in patients undergoing other common surgeries, such as gallbladder surgery, appendectomies, colectomies and cardiac surgery,” he added. “It is important because it helps understand to what degree immunosuppression might impact risk after these common surgeries.”
To assess the effects of biologics and glucocorticoids on the outcomes of surgeries other than joint replacement, George and colleagues conducted a retrospective cohort study of Medicare data from 2006 to 2015. For this study, the researchers sought out adults with rheumatoid arthritis who underwent hip fracture repair, abdominopelvic surgery — specifically cholecystectomy, hysterectomy, hernia, appendectomy or colectomy — or cardiac surgery, including coronary artery bypass graft and mitral/aortic valve.
George and colleagues performed logistic regression with propensity-score-based inverse probability weighting to compare 90-day mortality and 30-day readmission among patients treated with methotrexate without a biologic or targeted synthetic DMARD, a TNF-inhibitor, or a non-TNF-inhibitor biologic or targeted synthetic DMARD less than 8 weeks prior to surgery. They used similar analyses to determine links between glucocorticoids and surgery outcomes. The researchers included 10,777 surgeries in their analysis, including 3,585 hip fracture, 5,025 abdominopelvic and 2,167 cardiac procedures.
According to the researchers, there was no increased risk for 90-day mortality or 30-day readmission among patients receiving a TNF inhibitor (mortality aOR = 0.83; 95% CI, 0.67-1.02; readmission aOR = 0.86; 95%CI, 0.75-0.993), or a non-TNFi biologic or targeted synthetic DMARD (mortality aOR = 0.78; 95% CI, 0.49-1.22; readmission aOR = 1.02; 95%CI, 0.78-1.33), compared with methotrexate. Stratifying the analyses by surgery resulted in similar results.
Study data did show mortality and readmission risk were higher among patients treated with 5 mg to 10mg of glucocorticoids daily (mortality aOR = 1.41; 95% CI, 1.08-1.82; readmission aOR = 1.26; 95% CI, 1.05-1.52), or more than 10mg each day (mortality aOR = 1.64; 95% CI, 1.02-2.64; readmission aOR = 1.6; 95% CI, 1.15-2.24), compared with glucocorticoids. However, these results varied when stratified by surgery.
“These results suggest that necessary non-elective surgeries do not need to be delayed in patients receiving biologic therapies,” George said. “For planned, elective surgeries, a brief interruption of biologic therapy is not unreasonable for many patients — as is outlined by the ACR guidelines — but prolonged interruptions in therapy are likely not needed. Importantly, these results suggest that glucocorticoids may be a bigger contributor to post-operative risks and that trying to get to the lowest glucocorticoid dose necessary before surgery may help improve outcomes.” – by Jason Laday
Disclosure: George reports a research grant from Bristol-Myers Squibb and the NIH, as well as consulting fees from AbbVie. Please see the study for all other authors’ relevant financial disclosures.
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