Risk of Biologics and Glucocorticoids in Patients with Rheumatoid Arthritis Undergoing Arthroplasty: A Cohort Study
Michael D. George, MD MSCE,1 Joshua F. Baker, MD MSCE,1,2,3 Kevin Winthrop, MD MPH,4 Evo Alemao,5 Lang Chen, PhD,6 Sean Connolly,5 Jesse Y. Hsu, PhD,3 Teresa A. Simon,5 Qufei Wu, MS,3 Fenglong Xie, MS,6 Shuo Yang, MS,6 and Jeffrey R. Curtis, MD MS MPH6Hip Knee
Background
Patients with rheumatoid arthritis (RA) are at increased risk of infections after arthroplasty, yet risks of specific biologic medications are unknown.
Objectives
To compare the risk of post-operative infection between different biologics and to evaluate the risk associated with glucocorticoids
Design
Retrospective cohort
Setting
Medicare and Truven MarketScan® administrative data January 2006-September 2015
Patients
Adults with RA undergoing elective inpatient primary or revision total knee or hip arthroplasty with recent infusion or prescription for abatacept, adalimumab, etanercept, infliximab, rituximab, or tocilizumab before surgery.
Measurements
Propensity adjusted analyses using inverse probability weights evaluated comparative risk of 30-day hospitalized infection and 1-year prosthetic joint infection (PJI) between biologics or glucocorticoid doses. Secondary analyses evaluated non-urinary hospitalized infection and 30-day readmission.
Results
We identified 10,923 surgeries among 9,911 biologic-treated patients. Outcomes were similar in patients treated with different biologics. Compared to an 8.16% risk of hospitalized infection and 2.14% 1-year cumulative incidence of PJI with abatacept, predicted risk from propensity-weighted models ranged from 6.87% (5.30–8.90) with adalimumab to 8.90% (5.70–13.52) with rituximab for hospitalized infection and from 0.35% (0.11–1.12) with rituximab to 3.67% (1.69–7.88) with tocilizumab for PJI. Glucocorticoids were associated with a dose-dependent increase in post-operative risk for all outcomes. Compared to patients not receiving glucocorticoids, predicted risk from propensity-weighted models for >10mg/day glucocorticoids was 13.25% (9.72–17.81) vs. 6.78% for hospitalized infection and 3.83% (2.13–6.87) vs. 2.09% for 1-year cumulative incidence of PJI.
Limitations
Potential for residual confounding, small sample size for rituximab and tocilizumab
Conclusion
Risk of hospitalized infection, prosthetic joint infection, and readmission after arthroplasty was similar across biologics. In contrast, glucocorticoid use, especially > 10mg/day, was associated with greater risk of adverse outcomes.
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