Perioperative Biologic Disease-Modifying Antirheumatic Drugs, Risks of Infections, and Wound Complications in Patients With Rheumatoid Arthritis Undergoing Elective Hand Surgery.

Abstract

Recommendations for perioperative management of biologic disease-modifying antirheumatic drugs (bDMARDs) in hand surgery were historically adopted from other surgical specialties. The purpose of our study was to estimate the risks of surgical site infections (SSIs) and wound healing failures in patients with rheumatoid arthritis (RA) treated with bDMARDs undergoing elective hand surgery. We queried the TriNetX Research Network for patients with RA taking disease-modifying antirheumatic drugs (DMARDs) within 6 months of elective hand surgery. Patients were stratified into conventional synthetic, biologic, and targeted synthetic DMARD subgroups. Among bDMARD users, patients with an active prescription within 1 dosing interval before surgery were classified as bDMARD continued; others were classified as discontinued. Ninety-day risks of SSIs, wound healing failures, and composite wound morbidity were estimated by coded data. Disease flare risks were estimated by treatment escalations at 30 and 90 days after surgery and included as exploratory analyses. Outcomes were compared across DMARD classes and between propensity-score matched cohorts of patients who continued versus discontinued bDMARDs perioperatively. A total of 7,929 patients with RA were treated with DMARDs. Complication risks were similar across DMARD classes. Among patients treated with biologic agents (n = 2,668; 33.6%), 908 (34.0%) continued and 1,760 (66.0%) discontinued bDMARDs. After matching 881 per cohort, patients who continued bDMARDs perioperatively had similar estimated risks of SSIs (2.0% vs 1.5%), wound healing failures (1.4% vs 1.4%), and composite wound morbidity (3.0% vs 2.5%), compared to those who discontinued therapy. Perioperative bDMARD continuation was associated lower risks of postoperative disease flares, as estimated by treatment-based proxies. Among patients with RA undergoing elective hand surgery, perioperative bDMARD continuation was not associated with significant increases in risks of wound healing failures or SSIs. A modest increase in SSI risk cannot be excluded given exposure misclassification and residual confounding. Prognosis IIc.