Many of the patients that Michael George and his colleagues at Penn Medicine see in their Philadelphia clinic elect to get surgery at some point. Common procedures for older patients are hip and knee replacements, and those surgeries are even more frequent among those with rheumatoid arthritis, due to prior inflammations stemming from their disease.
“We are often asked to recommend how long treatments like infliximab should be stopped before surgery, but we found that there was almost no information to guide what to do,” says Dr. George, a rheumatologist. “If stopping medications could help prevent infections, this could potentially be very important.”
But stopping medications for extended periods of time can lead to disease flare-ups, which can exacerbate surgeries and rehabilitations. “They key seemed to be trying to figure out the best timing for these medications before surgery that would lead to the fewest infections,” says Dr. George, lead author of the recent study “Perioperative timing of infliximab and the risk of serious infection after elective hip and knee arthroplasty” published in Arthritis Care & Research.
When Dr. Michael and his colleagues studied the timing of infliximab, a biologic, before surgery, they found among the 4,288 patients — who had rheumatoid arthritis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or ankylosing spondylitis and received infliximab within six months of their elective knee or hip surgery between 2007 and 2013 — that 270, or 6.3 percent, were hospitalized with infections within 30 days. The infection rate didn’t increase for patients who stopped taking infliximab less than four weeks prior to surgery versus 8 to 12 weeks prior.
“We found that the timing of infliximab before surgery did not make much difference in the risk of infection,” Dr. George says.
That finding caught Dr. George and his colleagues, why expected that timing infliximab very close to surgery would have increased infections, off guard. The researchers had anticipated pinpointing the perfect timing to tell physicians to stop administering the medication. But instead they found that the medication could be stopped significantly earlier.
“Perhaps we shouldn’t have been surprised,” Dr. George says. “We knew from previous studies that methotrexate seems to be fairly safe to continue in patients having surgery. We also knew that stopping infliximab might lead to more prednisone use and more disease flare-ups that could increase, rather than decrease, the risk of infection.”
Other factors had a more important impact on infection risks, Dr. George and colleagues found. Those include patients being older, sicker, or having more complicated surgery. “These are things that are hard to change,” Dr. George says. “One important thing we found, though, is that patients who were taking higher doses of prednisone — especially more than 10 milligrams per day — were more likely to get an infection after surgery.”
Both patients and physicians need to understand that the best time to have surgery is when inflammation is well controlled and patients are taking the lowest dosage of prednisone possible, Dr. George advises. “Ideally either on none or on very low dose prednisone,” he says.
Prednisone dose, he says, may be more important than how medications like infliximab are timed in relation to surgery.
“Stopping infliximab for long periods of time does not seem to help prevent infections, and if patients have flare-ups of their disease from stopping infliximab and need to take more prednisone, this could actually be a big problem before surgery,” he says. He cautions, however, “Of course each case is different, and it is key for patients and physicians to communicate well, especially before surgery.”
Much remains unknown despite the recent study, and Dr. George notes that future research will address whether other biologics ought to be stopped before surgery.
“We also aren’t sure what to recommend in patients who are undergoing other types of surgery, like gall bladder removal, bowel surgery, or heart surgery,” he says. “We plan to study the timing of additional medications and also plan to look at infections after other types of surgery.”