This article is a collaboration between MedPage Today and:
WASHINGTON -- Patients with inflammatory bowel disease (IBD) being treated with corticosteroids had an increased risk for joint infection after joint replacement surgery, a retrospective study found.
Compared with aminosalicylate treatment, corticosteroid use was associated with more than twice the risk of serious infection after joint replacement (HR 2.3, 95% CI 1.3-4.1, P=0.006), reported Martin H. Gregory, MD, of Washington University in St. Louis.
In contrast, the use of tumor necrosis factor (TNF) inhibitors had no associated risk (HR 1.2, 95% CI 0.5-2.8, P=0.7), he reported here at Digestive Disease Week.
Action Points
- Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
Treatment with immunomodulators also was not associated with greater risk of serious infection (HR 0.7, 95% CI 0.3-1.8, P=0.5).
Concerns have been raised about the potential for anti-TNF agents to interfere with wound healing, potentially putting patients at risk of infections if they require surgery. "It's not uncommon for gastroenterologists to hear from surgeons asking about risks in taking IBD patients to the OR, and particularly about the effects of IBD medications on infection risk. But there is little evidence to provide guidance in this setting," Gregory said.
Most studies of surgery in patients with IBD have focused on abdominal surgery, and in those studies the effects of anti-TNF agents on infection risk have been conflicting.
But patients with IBD also do need to have surgery for conditions not related to the IBD. "There are over a million patients with IBD in the U.S., and the incidence is increasing. The IBD population is also aging, so it's likely that more IBD patients are going to be evaluated for joint replacement," he said.
Accordingly, Gregory's group conducted a retrospective case-control study using the Truven MarketScan claims database, identifying 1,455 patients with IBD who had knee, hip, or shoulder replacement surgery from 2006 to 2014. Ten controls were identified for each patient, matched according to the joint replaced.
The primary outcome was serious infection, a composite of joint infection, surgical site infection requiring intervention, pneumonia, sepsis, or Clostridium difficile infection within 3 months after the surgery.
A total of 43% of the patients had Crohn's disease (CD), 50% had ulcerative colitis (UC), and 7% had indeterminate colitis.
Their mean age was 56, and the knee was most commonly the joint being replaced.
More than half of patients were on aminosalicylates, and 13% were on corticosteroids alone, without having received any steroid-sparing agents in the 6 months prior to surgery.
As would be expected in patients undergoing elective surgery, their IBD seemed to be well controlled. Only 3% had been hospitalized in the 6 months before surgery, and less than 1% had surgery for an IBD complication in that time period.
In the 90 days after surgery, serious infections developed in 3.92% of IBD patients and 2.38% of controls, which was a statistically significant difference (P<0.01), he reported.
Serious infections occurred in 5.4% of patients with CD and in 3.4% of those with UC. Joint infections, including infected prosthesis, septic arthritis, and osteomyelitis developed in 1.7% of the CD patients and in 1.3% of the UC patients.
Complications of IBD, such as bowel obstruction or emergency department visits, occurred in 3.7% and 1.7% of the CD and UC groups, respectively, and escalation of therapy was required in 3.8% and 5.5%. Venous thromboembolism developed in 7% and 5.2%, respectively, while 90-day readmissions were seen in 7.6% and 14.1%.
Study limitations included its reliance on administrative data, so little information was available on disease activity, symptoms, and laboratory findings, and the fact that none of the patients were age >65.
The study showed that patients on anti-TNF or immunomodulators do not appear to be at increased risk associated with their medications, so they may be able to take advantage of a procedure that could significantly improve their quality of life. "Our results also reinforce the importance of escalating patients from steroids to steroid-sparing agents," Gregory concluded.
Primary Source
Digestive Disease Week
Gregory MH, et al "Inhibitors are Not Association with Increased Risk of Infection after Joint Replacement Surgery" DDW 2018; Abstract 160.