Session Information
Date: Monday, November 6, 2017
Session Type: ACR Poster Session B
Session Time: 9:00AM-11:00AM
Background/Purpose:
Rheumatoid arthritis (RA) patients have a higher frequency of requiring surgical procedures and worse surgical outcome. However, literature regarding post-surgical infectious outcome associated with combination of modifying anti-rheumatic drugs (DMARDs) and biologics is scare. The aim of the study is to assess whether the risk of post-operative infectious complications among RA patients is affected by discontinued methotrexate(MTX) and Tumor Necrosis Factor Inhibitor (TNFi) prior to surgery during perioperative period.
Methods:
Using the United States Veterans Affairs (VA) databases, we identified surgical procedures in a 18-year cohort of RA patients, who were on at least 1 DMARDs or 1 biologic agent in the perioperative period. Surgeries were divided into the following groups: patients treated with methotrexate (MTX) and etanercept (ETA) combination therapy, and those treated MTX and adalimumab (ADA) combination therapy. MTX is continued throughout the surgery. The risk of infection is compared among groups that continue vs discontinue within 90 days, 60 days and 30days of the surgery. Infection includes pneumonia, urinary tract infection and wound infection. Primary endpoints are total infectious complication. Unconditional multilevel mixed effect logistic regression model was used for analysis. Covariates include chronic steroid use status and modified Charlson score. Statistical significance is defined as p<0.05.
Results:
Table 1. Post-operative infection with MTX continued and TNFi discontinued within 90 days
|
Continue methotrexate Continue (reference) vs disontinue |
Odds ratio |
95% CI |
P value |
Observations |
|
|
Discontinue >90 days |
etanercept |
0.64 |
0.28~1.47 |
0.29 |
811 |
|
adalimumab |
0.53 |
0.21~1.34 |
0.18 |
685 |
|
|
Discontinue <90 days |
etanercept |
1.04 |
0.26~4.17 |
0.96 |
811 |
|
adalimumab |
1.74 |
0.51~5.98 |
0.38 |
685 |
|
Table 2. Post-operative infection with MTX continued and TNFi discontinued within 60 days
|
Continue methotrexate Continue (reference) vs disontinue |
Odds ratio |
95% CI |
P value |
Observations |
||
|
Discontinue >60 days |
etanercept |
0.68 |
0.30~1.51 |
0.34 |
820 |
|
|
adalimumab |
0.50 |
0.20~1.28 |
0.15 |
691 |
||
|
Discontinue <60 days |
etanercept |
0.76 |
0.15~3.77 |
0.73 |
820 |
|
|
adalimumab |
2.64 |
0.75~9.27 |
0.13 |
691 |
||
Table 3. Post-operative infection with MTX continued and TNFi discontinued within 30 days
|
Continue methotrexate Continue (reference) vs disontinue |
Odds ratio |
95% CI |
P value |
Observations |
|
|
Discontinue >30 days |
etanercept |
0.65 |
0.29~1.45 |
0.29 |
830 |
|
adalimumab |
0.59 |
0.24~1.45 |
0.25 |
702 |
|
|
Discontinue <30 days |
etanercept |
1.11 |
0.21~5.82 |
0.90 |
830 |
|
adalimumab |
2.09 |
0.41~10.53 |
0.37 |
702 |
|
Conclusion:
When MTX is continued through surgery for patients with RA, there is a trend towards lower risk of post-operative infection when TNFi was discontinued before surgery. Sensivity analyses of TNFi discontinuation at 30-60-90 days before surgery yielded similar results. However, the reduced infection risks did not reach statistical significance. This could be because of the heterogeneity of surgeries in our study. Further analyses looking at specific types of surgeries may help to ascertain this.
To cite this abstract in AMA style:
Juo HH, Ng B. Perioperative Management of Methotrexate and Tumor Necrosis Factor Inhibitor Combination Therapy in Rheumatoid Arthritis Patients [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/perioperative-management-of-methotrexate-and-tumor-necrosis-factor-inhibitor-combination-therapy-in-rheumatoid-arthritis-patients/. Accessed .« Back to 2017 ACR/ARHP Annual Meeting
ACR Meeting Abstracts - https://acrabstracts.org/abstract/perioperative-management-of-methotrexate-and-tumor-necrosis-factor-inhibitor-combination-therapy-in-rheumatoid-arthritis-patients/