Reduction in Upper Limb Joint Surgery Among Rheumatoid Arthritis Patients: An Interrupted Time‐Series Analysis Using Danish Health Care Registers

Abstract

Objective Joint replacement surgery is a proxy of severe joint damage in rheumatoid arthritis (RA). The aim of this study was to assess the impact of the introduction of biologic disease‐modifying antirheumatic drugs (bDMARDs) on the incidence rate (IR) of upper limb joint replacements among newly diagnosed RA patients. Methods Using the Danish National Patient Register, patients with incident RA from 1996–2012 were identified. Each patient was matched on age, sex, and municipality, with up to 10 general population controls. The age‐ and sex‐standardized 5‐year IR per 1,000 person‐years of a composite outcome of any first joint replacement of the finger, wrist, elbow, or shoulder was calculated, and an interrupted time‐series analysis was undertaken to investigate trends and changes of the IR in the pre‐bDMARD (1996–2001) and the bDMARD eras (2003–2012), with a 1‐year lag period in 2002. Results In total, 18,654 incident patients with RA were identified (mean age 57.6 years, 70.5% women). The IR of joint replacements among patients with RA was stable at 2.46 per 1,000 person‐years (95% confidence interval [95% CI] 1.96, 2.96) from 1996 to 2001 but started to decrease from 2003 onwards (–0.08 per 1,000 person‐years annually [95% CI –0.20, 0.02]). Compared with patients with RA, the IR among controls in 1996 was 1/17 and increased continuously throughout the study period. Conclusion The IR of upper limb joint replacements started to decrease among patients with RA from 2002 onwards, whereas it increased among controls. Our results suggest an association between the introduction of bDMARDs and a lower need of joint replacements among patients with RA.

Perioperative management of patients with inflammatory rheumatic diseases

“…With this in mind, the management of antirheumatic medications that could potentially increase this risk is an important decision that many physicians and patients face at some point during the course of the rheumatic disease. Since the introduction of bDMARD therapies in the early 2000s, surgical interventions have fortunately decreased, not only in Germany but also in many other countries [49][50][51][52][53]. Nevertheless, surgical interventions are still more frequent in patients with inflammatory rheumatic diseases than in the healthy population [54].…”

A Novel Radiographic Measurement Method for the Evaluation of Metatarsophalangeal Joint Dislocation of the Lesser Toe in Patients with Rheumatoid Arthritis

“…They showed that the prevalence among cases of elbow, shoulder, and ankle replacement surgeries decreased by 50%, 18%, and 38%, respectively. Cordtz et al [ 2 ] evaluated the incidence of joint replacement before (1996–2001) and after (2003–2012) the introduction of bDMARDs in patients diagnosed with RA in Denmark between 1996 and 2012. They reported that the incidence of joint replacement in RA patients was stable from 1996 to 2001 but started to decrease from 2003, suggesting an association between the introduction of bDMARDs and a lower need for joint replacements among patients with RA.…”

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

“… 3 While use of both conventional and targeted DMARDs has increased, and the rates of upper extremity and small joint surgery have decreased, the rates of total hip (THA) and total knee arthroplasty (TKA) have not. 2 4 In one recent study using propensity matching and adjusting for disease activity, tumour necrosis factor inhibitor (TNFi) use was not associated with decreased rates of THA or TKA. 5 Therefore, patients with RA continue to undergo THA and TKA, despite high utilisation of targeted and csDMARDs and glucocorticoids, which most patients are taking at the time of surgery.…”