Safety of etanercept therapy in rheumatoid patients undergoing surgery: preliminary report

Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations

With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.

Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations

With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.

Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations

With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.

Patients With Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following a Hallux Valgus Procedure

BACKGROUND

Patients with a history of opioid use disorder (OUD) tend to have more complications, higher readmission rates, and increased costs following orthopaedic procedures. This study evaluated patients undergoing hallux valgus correction for their odds of increased (1) readmission rates, (2) emergency room (ER) visits, and (3) costs.

METHODS

Patients undergoing hallux valgus corrections with OUD history were identified using a national Medicare administrative claims database of approximately 24 million orthopaedic surgery patients. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. The query yielded 6318 patients (OUD = 1276; NUD = 5042) who underwent a hallux valgus correction. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day ER visits, and 90-day episode-of-care costs. Demographics, odds ratios (ORs), ECI, and cost were assessed as appropriate using a Pearson χ² test, logistic regression, and a t test. A P value <.05 was considered statistically significant.

RESULTS

There were no significant differences in demographics between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission (9.56% vs 6.04%; OR = 1.55; P < .001) and 30-day ER visits (0.86% vs 0.35%; OR = 2.42; P = .021) and incurred greater 90-day episode-of-care costs ($7208.28 vs $6134.75; P < .001) compared with NUD patient controls.

CONCLUSION

The study demonstrates the possible influence of OUD on higher odds of readmission, ER visits, and costs following a hallux valgus correction.

LEVELS OF EVIDENCE

Level III: Retrospective cohort study.

Management of Biologic Therapy in Moderate to Severe Psoriasis in Surgical Patients: Data From the Spanish Biobadaderm Registry

BACKGROUND AND OBJECTIVE

We now have considerable experience in the use of biologic agents to treat psoriasis, but doubts about management arise in certain clinical settings. Surgery is one of them. Although treatment guidelines advise that biologics be suspended before major surgery, data about actual clinical practices and associated complications are lacking. We aimed to analyze current practice in the clinical management of these cases.

METHODS

Retrospective study of cases in the Biobadaderm database. We analyzed the management of biologic therapy in patients with psoriasis who underwent surgical procedures.

RESULTS

Forty-eight of the 2113 patients registered in Biobadaderm underwent surgery. The largest percentage of procedures (31%) involved skin lesions. Biologic treatment was interrupted in 42% of the cases. No postsurgical complications were significantly related to treatment interruption. Likewise we detected no associations between treatment interruption and other variables, such as sex, age, or duration or severity of psoriasis.

CONCLUSION

Continuity of biologic treatment and the risk of postsurgical complications were not associated in this study, although conclusions are limited by the small sample size.

[Peri-operative management of disease modifying anti-rheumatic drugs: recommendations based on a meta-analysis]

The objective of this paper is make recommendations for the perioperative management of antirheumatic treatment based on the best available evidence. A systematic review was performed including studies in which patients with rheumatic diseases treated with biological and non-biological disease-modifying antirheumatic drugs (DMARDs) had undergone surgery. A total of 5,285 studies were recorded, of which 27 were finally included. These contained information on 5,268 patients and 7,933 surgeries. The majority were women (mean age 55 years) were diagnosed with rheumatoid arthritis, and the most studied drug was methotrexate (MTX). The final recommendations include: maintaining treatment with MTX or leflunomide in the perioperative period in the absence of other risk factors for postoperative complications (Level of Evidence 1c, Grade D recommendation). Biological DMARDs should be temporarily suspended, or the surgery scheduled as far as possible from the last dose, and, if there were other risk factors a space at least two doses (Level of Evidence 2c; Grade D recommendation).

Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs

The aim of this study was to identify risk factors for acute surgical-site infection (SSI) after total joint arthroplasty in rheumatoid arthritis (RA) patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs). We performed a retrospective study of all consecutive total hip (THA) and total knee (TKA) arthroplasties performed during a 5-year period (THA 81; TKA 339). Multivariate logistic regression analysis was performed to identify SSI risk factors. Of the patients undergoing THA or TKA, 24 cases (5.7%) developed a superficial incisional SSI requiring the use of antibiotics and three cases (0.7%) developed an organ/space SSI necessitating surgical treatment to remove the artificial joint prosthesis. Multivariate logistic regression analysis revealed that the use of biologic DMARDs [P = 0.0007, odds ratio (OR) = 5.69; 95% confidence interval (CI) 2.07-15.61] and longer RA duration (P = 0.0003, OR = 1.09; 95% CI 1.04-1.14) were the only significant risk factors for acute SSI. Furthermore, an analysis that individually evaluated major agents (n > 10) adjusted for disease duration indicated that tumor necrosis factor alpha blockers increased the risk of SSI (infliximab P = 0.001, OR = 9.80, 95% CI 2.41-39.82; etanercept P = 0.0003, OR = 9.16, 95% CI 2.77-30.25). We found that the use of infliximab or etanercept and longer disease duration were associated with an increased risk of acute SSI in RA patients. Prospective studies are thus needed to determine the safety of biologic DMARDs in the perioperative period.

Cachexia - an intrinsic factor in wound healing

Systemic diseases are intrinsic factors that alter and may impair the wound healing process. Cachexia is a manifestation of systemic, often chronic, diseases and is characterised by systemic inflammation, appetite suppression and skeletal muscle wasting. Anorexia in cachectic states is commonly associated with malnutrition. Malnutrition may cause impaired healing. Therefore, it would follow that cachexia could influence wound healing because of reduced food intake. However, the lack of response to measures to reverse cachexia, such as supported nutrition, would suggest that a direct causal link between anorexia and weight loss in cachexia is too simple a model. To date, there is no published literature that examines the role of cachexia in human wound healing specifically. This article aims to demonstrate that cachexia is an intrinsic factor in wound healing. The role of the common mediators in wound healing and in cachexia are compared - specifically inflammation, including the nitric oxide synthase pathway, collagen deposition and reepithelialisation.

[Management of problematic clinical situations in rheumatoid arthritis patients. Surgery]

Even though clinical management and treatment of rheumatoid arthritis patients has improved, orthopedic surgery is now a common situation in daily clinical practice. Usually, the rheumatologist is who manages the anti-rheumatic treatment in the perioperative period and decisions are not always supported by scientific information of suitable quality.