February 27, 2019
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Holding abatacept before hip, knee surgery may not improve outcomes

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Jeffrey R. Curtis

Withholding abatacept for 4 weeks or more prior to hip or knee replacement surgery did not lower the risk for infection among patients with rheumatoid arthritis, according to data published in Arthritis Care & Research.

“There is a great deal of ambiguity as to when someone on a biologic might need to hold or stop it ahead of elective surgery,” Jeffrey R. Curtis, MD, MS, MPH, of the University of Alabama at Birmingham, told Healio Rheumatology. “The current recommendations that exist (eg, American College of Rheumatology) are based on very limited data that have some major limitations, mainly that they compare biologic users vs. nonusers. However, that is not really the right group of patients to study.”

Instead, Curtis and colleagues studied only those patients who were receiving IV abatacept (Orencia, Bristol Myers Squibb), and determined whether withholding the drug increased the risk for adverse outcomes by comparing various times that patients stopped prior to surgery with respect to serious infection, including prosthetic joint infection, he said. They accomplished this through a retrospective cohort study of U.S. Medicare and Truven MarketScan administrative data, from 2006 to September 2015.

 
Withholding abatacept for 4 weeks or more prior to hip or knee replacement surgery did not lower the risk for infection among patients with RA, according to data.
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The researchers focused on 1,780 adult patients with RA who received abatacept within 6 months of surgery. These patients accounted for 1,939 elective primary or revision hip or knee arthroplasties. Curtis and colleagues used propensity weighted analyses to compare the risk for 30-day hospitalized infection, as well as 1-year prosthetic joint infection, among patients who ceased abatacept at various times. In addition, secondary analyses evaluated nonurinary hospitalized infection and 30day readmission.

According to the researchers, there were 175 cases of hospitalized infection, 115 non-urinary hospitalized infections, 39 prosthetic joint infections and 114 30-day readmissions. The researchers found no significant differences between outcomes among patients who stopped abatacept less than 4 weeks prior to surgery compared with 4 to 8 weeks or more than 8 weeks. The ORs were 0.93 (95% CI, 0.651.34) for hospitalized infection, 0.93 (95% CI, 0.61.44) for nonurinary hospitalized infection and 1 (95% CI, 0.651.54) for 30-day readmission. The HR for prosthetic joint infection was 1.29 (95% CI, 0.622.69).

In addition, daily treatments of more than 7.5 mg of glucocorticoids were associated with a greater risk for hospitalized infection (OR = 2.19; 95% CI, 1.283.77) and nonurinary hospitalized infection (OR = 2.38; 95% CI, 1.224.64).

“This is clinically relevant because it implies that patients don’t need to be off RA biologics for prolonged periods of time before elective surgery,” Curtis said. “If they are off too long, they run the risk of flare of their RA, for which they are often given steroids, which increase infection risk and may impair wound healing.” – by Jason Laday

Disclosure: Curtis reports a research grant from Bristol-Myers Squibb, as well as consulting fees from AbbVie, Bristol-Myers Squibb, Lilly, Myriad, Roche/Genentech, UCB, Amgen, Janssen, Pfizer and Corrona. Please see the study for all other relevant financial disclosures.