ACP PRESENTATION 2012

– Steroids and Leflunomide, Not Biologics Are The Major

Risk Factors For Infection Following Total Joint

Arthroplasty

Ranjani Somayaji B.Sc.PT., MD

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und

Rheumatoid arthritis (RA)

patients are at risk for

infectious complications

following orthopedic

procedures due to underlying co-morbidities

& RA treatment The effect of biologic

therapies on the risk of

infections is still controversial…

Goh L, Jewell T, Laversuch C & Smanta A. Should anti-TNF therapy be discontinued in rheumatoid arthritis patients undergoing orthopaedic surgery? A systematic review of the evidence. Rheumatol Int 2012;32:5-13.

Obje

ctiv

e

To determine whether

biologic therapies increase the risk of post-operative infection (surgical site

or any site) in RA or adult juvenile idiopathic arthritis (JIA)

patients undergoing hip or knee total joint

arthroplasty

Meth

ods

Subjects: RA/JIA undergoing hip or knee

TJA between January 1,

2000 – December 31,

2010 Total of 381 procedures in

259 patients performed

Demographic + clinical

data collected for up to 1

year

Hyp

oth

esi

s

Patients with RA on biologic

therapy will have an increased

incidence of post-operative

infection following hip or knee

TJA as compared with RA

patients on standard disease

modifying agents…

Table

1

Demographics n=259

Female 71%

Age (mean) 63 years

Smoking 13% current13% past74% never

BMI mean 27.6underweight 5%normal weight 37%overweight 24%obese 33%

Comorbidity Hypertension 43%Diabetes 10%Coronary artery disease 14%Chronic kidney disease 3%

Prednisone Use None 71%1-15 mg/day 27%>15 mg/day 2%

Biologic Use 18%

Resu

lts

– Pa

rt 1

Relative Risk for Infection Following Total Joint Arthroplasty by Therapy

Therapy Infection rates

Relative Risk

Biologics 2/70 0.90 (0.25-3.26)p = 0.8768

Steroids (<15mg/d)

7/106 2.03 (1.23-3.36)*p= 0.0271

Steroids (>15mg/d)

3/7 23.1 (5.79-91.87)p<0.0001

Biologic + Steroid

1/18 1.81(0.26-12.50)p=0.5493

Methotrexate 1/145 0.21 (0.03-1.40)p=0.0312

Leflunomide 3/34 2.98 (1.06-8.39)p=0.0472

Combination DMARDs

0 cases -

Resu

lts

– Pa

rt 2

Relative Risk for Infection Following Total Joint Arthroplasty by Comorbidity

Comorbidity Infection rates

Relative Risk

Current Smoker

1/34 0.93 (0.14-6.26)p=0.9419

Obesity 3/130 0.73 (0.27-1.95)p=0.4983

Hypertension 4/156 0.81 (0.36-1.81)p=0.5807

Coronary Artery Disease

4/54 2.45 (1.06-5.69)p=0.0539

Diabetes 3/42 2.36 (0.85-6.57)p=0.1174

Dis

cuss

ion

Biologic therapy & underlying co-morbidities

do not confer an increased

risk of post-operative

infection in RA patients

undergoing hip or knee

total joint arthroplasty

Moderate to high dose

steroids & leflunomide

increase the risk of infection Limitations… Future studies….

QU

ESTIO

NS?

Thank you to Dr. Liam Martin & Dr. Cheryl

Barnabe