acp presentation 2012 – steroids and leflunomide, not biologics are the major risk factors for...

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ACP PRESENTATION 2012 – Steroids and Lefluno mide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplas ty Ranj ani Somayaji B .Sc.PT., MD

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Page 1: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

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

Page 2: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

Dis

claim

er Wishing I had one?...

Residency Salary?

Page 3: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

Back

gro

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.

Page 4: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

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

Page 5: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

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

Page 6: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

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…

Page 7: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

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%

Page 8: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

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 -

Page 9: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

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

Page 10: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

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….

Page 11: ACP PRESENTATION 2012 – Steroids and Leflunomide, Not Biologics Are The Major Risk Factors For Infection Following Total Joint Arthroplasty Ranjani Somayaji

QU

ESTIO

NS?

Thank you to Dr. Liam Martin & Dr. Cheryl

Barnabe