Glucocorticoids Associated with Increased Infection Risk after TJA in Patients with RA

    Glucocorticoid use, especially with dosages above 10 mg per day, was associated with a greater risk for adverse events among patients with rheumatoid arthritis (RA) undergoing total joint arthroplasty, according to a cohort study from the University of Pennsylvania.

    In contrast, the risk of hospital-acquired infection, periprosthetic joint infection, and readmission was similar across biologics.

    The study findings have been published in Annals of Internal Medicine.

    Many patients with RA undergo total hip or total knee arthroplasty. Biologic medications are increasingly used to treat RA and are associated with greater risk for serious infection, yet it is not known how these medications affect the risk of infection after surgery and whether risk varies across medications.

    RELATED: New Guideline Aims to Reduce Infections in TJA Patients with Rheumatic Disease

    The researchers used Medicare and Truven MarketScan administrative claims data to compare infection risk across biologic therapies used by 9911 adults with rheumatoid arthritis who underwent primary or revision hip or knee replacement surgery between January 2006 and September 2015. They also evaluated the risk for postoperative infection associated with glucocorticoids. Patients were included if they had used any of the following drugs before surgery:

    • Abatacept
    • Adalimumab
    • Etanercept
    • Infliximab
    • Rituximab
    • Tocilizumab

    The researchers found that the rates of serious postoperative infection and 30-day readmission were similar among the biologics. However, glucocorticoids were associated with a dose-dependent increase in the risk for adverse outcomes, with greater risk even with modest doses. According to the researchers, these findings suggest that limiting glucocorticoid use should be a focus of perioperative management.

    The authors of an accompanying editorial from the University of Toronto [1] agree that the study provides compelling evidence of the risk for adverse postoperative outcomes with glucocorticoids. But they say that the study does not resolve the question of whether withholding biologic therapies in the perioperative period reduces patients’ overall risk for infection. They suggest that more research is critical to answering that question.

    Of note, the American College of Rheumatology and the American Association of Hip and Knee Surgeons collaborated a few years ago on the development of guidelines for the management of anti-rheumatic medications during the perioperative period to reduce the risk of periprosthetic joint infection in patients with rheumatic disease who are undergoing total joint arthroplasty. [2] The guidelines panel included orthopaedic surgeons and rheumatologists.


    George MD, Baker JF, Winthrop K, et al. Risk of biologics and glucocorticoids in patients with rheumatoid arthritis undergoing arthroplasty: a cohort study. Ann Intern Med. 2019 May 21. doi: 10.7326/M18-2217. [Epub ahead of print].


    1. Ravi B. Hawker G. Elucidating the risks and benefits of withholding biologics to optimize surgical outcomes. Ann Intern Med. 2019 May 21. doi: 10.7326/M19-1088. [Epub ahead of print]
    2. Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. J Arthroplasty. 2017 Sep;32(9):2628-2638. doi: 10.1016/j.arth.2017.05.001. Epub 2017 Jun 16.