If you use a biologic drug for rheumatoid arthritis (RA), you probably know that doing so increases your chances of developing a serious infection like pneumonia or tuberculosis. While the benefits of the medication might very well outweigh the risks for you most of the time, the equation changes when you’re preparing for surgery (which in and of itself makes you susceptibleto infection). 

That’s why patients who are about to get a hip or knee replacement are usually told by their doctors to stop their biologic ahead before the procedure. But when, exactly, should you cut it off?

The answer isn’t so clear-cut, because if you stop a drug that’s controlling your disease too soon you could end up having a flare; if you stop too close to surgery, you might be leaving yourself extra vulnerable to developing a surgical-related infection. The best option, at least for patients who use the biologic abatacept (Orencia), seems to be to skip just one dose prior to surgery.

That’s the conclusion of a new analysis, published in the journal Arthritis Research & Therapy. The authors determined that skipping intravenous abatacept for more than four weeks prior to surgery — the medication is usually taken every four weeks — does not provide any additional benefits in terms of lowering the risk of post-op infections.

The study authors reviewed Medicare and Truven MarketScan databases to study RA patients who had used intravenous abatacept within six months of getting knee or hip arthroplasty (joint replacement) between 2006 and 2015. Their sample ended up including a total of nearly 2,000 surgical cases. 

“These results suggest that holding therapy [for more than a few weeks] is not likely to substantially improve post-operative outcomes and that any differences in infection risk, if they exist, are likely to be small. Prolonged holding of therapy, however, increases the risk of disease flares, which could potentially interfere with rehabilitation,” the authors wrote, also noting that patients who stop abatacept for too long are more apt to need higher levels of glucocorticoids (steroids), which have their own downsides (like increases in blood pressure, blood sugar, and swelling). 

“It may reasonable pre-operatively to time intravenous abatacept infusions to occur two to four weeks prior to surgery. Post-operatively, if the surgical site is healing well and treatment is resumed 14 days after surgery as suggested in [American College of Rheumatology] guidelines,then there will be little to no interruption of abatacept.”

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