Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 May;79(5):573-580.
doi: 10.1136/annrheumdis-2019-216802. Epub 2020 Mar 24.

Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery

Michael D George  1 , Joshua F Baker  2   3 , Kevin L Winthrop  4 , Seth D Goldstein  5   6 , E Alemao  7 , Lang Chen  8 , Qufei Wu  2 , Fenglong Xie  8 , Jeffrey R Curtis  8
Affiliations

Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery

Michael D George et al. Ann Rheum Dis. 2020 May.

Abstract

Objectives: The impact of immunosuppression on postoperative outcomes has primarily been studied in patients undergoing joint replacement surgery. We aimed to evaluate the impact of biologics and glucocorticoids on outcomes after other major surgeries.

Methods: This retrospective cohort study used Medicare data 2006-2015 to identified adults with rheumatoid arthritis undergoing hip fracture repair, abdominopelvic surgery (cholecystectomy, hysterectomy, hernia, appendectomy, colectomy) or cardiac surgery (coronary artery bypass graft, mitral/aortic valve). Logistic regression with propensity-score-based inverse probability weighting compared 90-day mortality and 30-day readmission in patients receiving methotrexate (without a biologic or targeted synthetic disease-modifying antirheumatic drug (tsDMARD)), a tumour necrosis factor inhibitor (TNFi) or a non-TNFi biologic/tsDMARD <8 weeks before surgery. Similar analyses evaluated associations between glucocorticoids and outcomes.

Results: We identified 10 777 eligible surgeries: 3585 hip fracture, 5025 abdominopelvic and 2167 cardiac surgeries. Compared with patients receiving methotrexate, there was no increase in the risk of 90-day mortality or 30-day readmission among patients receiving a TNFi (mortality adjusted OR (aOR) 0.83 (0.67 to 1.02), readmission aOR 0.86 (0.75 to 0.993)) or non-TNFi biologic/tsDMARD (mortality aOR 0.78 (0.49 to 1.22), readmission aOR 1.02 (0.78 to 1.33)). Analyses stratified by surgery category were similar. Risk of mortality and readmission was higher with 5-10 mg/day of glucocorticoids (mortality aOR 1.41 (1.08 to 1.82), readmission aOR 1.26 (1.05 to 1.52)) or >10 mg/day (mortality aOR 1.64 (1.02 to 2.64), readmission aOR 1.60 (1.15 to 2.24)) versus no glucocorticoids, although results varied when stratifying by surgery category.

Conclusions: Recent biologic or tsDMARD use was not associated with a greater risk of mortality or readmission after hip fracture, abdominopelvic or cardiac surgery compared with methotrexate. Higher dose glucocorticoids were associated with greater risk.

Keywords: DMARDs (biologic); infections; orthopaedic surgery; rheumatoid arthritis.

PubMed Disclaimer

Conflict of interest statement

Competing interests: MG has received a research grant from Bristol-Myers Squibb and the National Institutes of Health and consulting fees from AbbVie. JFB has received consulting fees from Bristol-Myers Squibb and Gilead. KLW has received research grants from Pfizer and Bristol-Myers Squibb, and consulting fees from Pfizer, AbbVie, UCB, Lilly, Galapagos, GSK, Roche, and Gilead. EA is an employee of Bristol-Myers Squibb. JRC has received research grants from the Patient Centered Outcomes Research Institute and research grants and consulting fees from Bristol-Myers Squibb, Amgen, AbbVie, Corrona, Janssen, Lilly, Myriad, Pfizer, UCB and Regeneron.

Figures

Figure 1:
Figure 1:. Cohort Selection
Figure 2:
Figure 2:. Associations of biologic use with mortality and readmission by surgery type.
Odds ratios from inverse probability weighted logistic regression models. Propensity score models include the same variables as shown in online supplementary Table S2 and are re-calculated for each surgery type with unbalance covariates added to weighted models. Hip = hip fracture surgery, Abd = abdominopelvic surgery, Cardiac = cardiac surgery, TNF = tumor necrosis factor inhibitor, tsDMARD = targeted synthetic disease modifying anti-rheumatic drug
Figure 3:
Figure 3:. Associations of glucocorticoid use with mortality and readmission by surgery type.
Odds ratios from inverse probability weighted logistic regression models. Propensity score models include the same variables as shown in Table 2 and are re-calculated for each surgery type with unbalance covariates added to weighted models. Hip = hip fracture surgery, Abd = abdominopelvic surgery, Cardiac = cardiac surgery
See this image and copyright information in PMC

References

    1. Cordtz RL, Zobbe K, Højgaard P, et al. Predictors of revision, prosthetic joint infection and mortality following total hip or total knee arthroplasty in patients with rheumatoid arthritis: a nationwide cohort study using Danish healthcare registers. Ann Rheum Dis 2018;77:281–8. doi:10.1136/annrheumdis-2017-212339 - DOI - PubMed
    1. Stundner O, Danninger T, Chiu Y-L, et al. Rheumatoid Arthritis vs Osteoarthritis in Patients Receiving Total Knee Arthroplasty: Perioperative Outcomes. The Journal of Arthroplasty 2014;29:308–13. doi:10.1016/j.arth.2013.05.008 - DOI - PMC - PubMed
    1. Ravi B, Escott B, Shah PS, et al. A systematic review and meta-analysis comparing complications following total joint arthroplasty for rheumatoid arthritis versus for osteoarthritis. Arthritis & Rheumatism 2012;64:3839–49. doi:10.1002/art.37690 - DOI - PubMed
    1. Salt E, Wiggins AT, Rayens MK, et al. Moderating effects of immunosuppressive medications and risk factors for post-operative joint infection following total joint arthroplasty in patients with rheumatoid arthritis or osteoarthritis. Semin Arthritis Rheum 2017;46:423–9. doi:10.1016/j.semarthrit.2016.08.011 - DOI - PMC - PubMed
    1. Schnaser EA, Browne JA, Padgett DE, et al. Perioperative Complications in Patients With Inflammatory Arthropathy Undergoing Total Hip Arthroplasty. J Arthroplasty 2016;31:2286–90. doi:10.1016/j.arth.2016.03.023 - DOI - PubMed

Publication types

MeSH terms

Substances