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

Abstract

ObjectivesThe 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.MethodsThis 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.ResultsWe 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.ConclusionsRecent 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.

‘Should we stop or continue conventional synthetic (including glucocorticoids) and targeted DMARDs before surgery in patients with inflammatory rheumatic diseases?’

“…A recent study using administrative data evaluated patients with RA undergoing hip fracture repair, abdominopelvic surgery, or cardiac surgery and found no increase in the risk of 30-day readmission, hospitalised infection, pneumonia or wound complications in patients receiving a TNFi or in patients receiving a non-TNFi targeted DMARD compared with patients receiving methotrexate without one of these therapies. 35 Similar to what has been seen in studies of arthroplasty, the timing of infliximab infusions prior to surgery was not associated with adverse outcomes. 35 …”

“… 35 Similar to what has been seen in studies of arthroplasty, the timing of infliximab infusions prior to surgery was not associated with adverse outcomes. 35 …”

“…A recent study using administrative data evaluated patients with RA undergoing hip fracture repair, abdominopelvic surgery, or cardiac surgery and found no increase in the risk of 30-day readmission, hospitalised infection, pneumonia or wound complications in patients receiving a TNFi or in patients receiving a non-TNFi targeted DMARD compared with patients receiving methotrexate without one of these therapies. 35 Similar to what has been seen in studies of arthroplasty, the timing of infliximab infusions prior to surgery was not associated with adverse outcomes. 35 While it remains uncertain whether interruption of a TNFi before surgery can improve postoperative outcomes, the ACR/AAHKS guideline for patients undergoing elective TKA and THA achieved consensus between the surgeons, rheumatologists and infectious disease specialists, recommending that all biologics be withheld for a short duration with surgery planned for the end of the dosing cycle.…”

Prognostic factors for the short-term mortality of patients with rheumatoid arthritis admitted to intensive care units

“…Additionally, despite the lack of a significant difference in dose-related risk of glucocorticoids in the multivariate analysis, a higher glucocorticoid dose appeared to be associated with an increased risk of mortality. Based on previous reports on the risks related to infections and medications, including glucocorticoid, csDMARDs, and bDMARDs [6,15,17,35,36,[39][40][41], a dose-related glucocorticoid was reported to increase the risk of infection, whereas csDMARDs were reported to reduce the risk and mortality in RA [15,42,43]. Treatment with glucocorticoids raised the incidence and hazard of adverse effects in RA patients, such as diabetes mellitus, osteoporosis, thrombotic stroke, CVD, serious infection, and death [44][45][46].…”

Prognostic factors for the short-term mortality of patients with rheumatoid arthritis admitted to intensive care units

“…Additionally, despite the lack of a signi cant difference in dose-related risk of glucocorticoids in the multivariate analysis, a higher glucocorticoid dose appeared to be associated with an increased risk of mortality. Based on previous reports on the risks related to infections and medications, including glucocorticoid, csDMARDs, and bDMARDs [6,15,17,36,39,40] [35,41], a dose-related glucocorticoid was reported to increase the risk of infection, whereas csDMARDs were reported to reduce the risk and mortality in RA [42] [15,43]. Treatment with glucocorticoids raised the incidence and hazard of adverse effects in RA patients, such as diabetes mellitus, osteoporosis, thrombotic stroke, CVD, serious infection, and death [44][45][46].…”