• Michael D George, Joshua F Baker, Kevin Winthrop, Evo Alemao, Lang Chen, Sean Connolly, Jesse Y Hsu, Teresa A Simon, Qufei Wu, Fenglong Xie, Shuo Yang, and Jeffrey R Curtis.
• University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania (M.D.G., J.Y.H., Q.W.).
• Ann. Intern. Med. 2019 Jun 18; 170 (12): 825-836.

BackgroundPatients with rheumatoid arthritis (RA) are at increased risk for infection after arthroplasty, yet risks of specific biologic medications are unknown.ObjectiveTo compare risk for postoperative infection among biologics and to evaluate the risk associated with glucocorticoids.DesignRetrospective cohort study.SettingMedicare and Truven MarketScan administrative data from January 2006 through September 2015.PatientsAdults with RA who were having elective inpatient total knee or hip arthroplasty, either primary or revision, and had a recent infusion of or prescription for abatacept, adalimumab, etanercept, infliximab, rituximab, or tocilizumab before surgery.MeasurementsPropensity-adjusted analyses using inverse probability weights evaluated comparative risks for hospitalized infection within 30 days and prosthetic joint infection (PJI) within 1 year after surgery between biologics or with different dosages of glucocorticoids. Secondary analyses evaluated non-urinary tract hospitalized infections and 30-day readmissions.ResultsAmong 9911 patients treated with biologics, 10 923 surgical procedures were identified. Outcomes were similar in patients who received different biologics. Compared with an 8.16% risk for hospitalized infection with abatacept, predicted risk from propensity-weighted models ranged from 6.87% (95% CI, 5.30% to 8.90%) with adalimumab to 8.90% (CI, 5.70% to 13.52%) with rituximab. Compared with a 2.14% 1-year cumulative incidence of PJI with abatacept, predicted incidence ranged from 0.35% (CI, 0.11% to 1.12%) with rituximab to 3.67% (CI, 1.69% to 7.88%) with tocilizumab. Glucocorticoids were associated with a dose-dependent increase in postoperative risk for all outcomes. Propensity-weighted models showed that use of more than 10 mg of glucocorticoids per day (vs. no glucocorticoid use) resulted in a predicted risk for hospitalized infection of 13.25% (CI, 9.72% to 17.81%) (vs. 6.78%) and a predicted 1-year cumulative incidence of PJI of 3.83% (CI, 2.13% to 6.87%) (vs. 2.09%).LimitationResidual confounding is possible, and sample sizes for rituximab and tocilizumab were small.ConclusionRisks for hospitalized infection, PJI, and readmission after arthroplasty were similar across biologics. In contrast, glucocorticoid use, especially with dosages above 10 mg/d, was associated with greater risk for adverse outcomes.Primary Funding SourceRheumatology Research Foundation, National Institutes of Health, and Bristol-Myers Squibb.

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