Orthopedics

SAN DIEGO – Patients with osteoarthritis of the knee who wore a patellofemoral brace for 6 weeks experienced a significant reduction in pain and in bone marrow lesion volumes in the patellofemoral region, compared with those who did not wear the brace, a multicenter trial showed.

"There’s a pressing need for nonsurgical intervention for knee osteoarthritis," Dr. David T. Felson said in a press briefing at the annual meeting of the American College of Rheumatology.

"There are no currently approved structure-modifying treatments. This has been a focus of studies that have been testing modifying treatments on hyaline cartilage, which changes slowly, necessitating expensive, long-term, large trials. Even so, mechanopathology such as that caused by malalignment or meniscal tears may make it impossible to protect cartilage in existing OA," he noted.

Dr. Felson, director of the Research in Osteoarthritis in Manchester group at the University of Manchester (England) and professor of medicine at Boston University, went on to note that bone marrow lesions (BMLs) "have been well shown to predict later cartilage loss in that location and correlate with pain and its severity. Recently, we showed that BMLs fluctuate in volume in as little as 6 weeks. Further, one small trial has suggested that zoledronic acid may shrink BMLs and reduce knee pain. That leads us to suggest that BMLs may be a viable treatment target in OA."

The patellofemoral joint "is a major source of knee pain in OA, and there has been little study of the efficacy of PF braces," he continued. "In a body mechanics study, PF bracing has been shown to increase the contact area of the PF joint. It may thereby lower the contact stress and shrink BMLs."

He and his associates set out to determine whether bracing would improve pain and lessen the volume of BMLs in patients with knee OA. They enrolled 126 patients with a mean age of 55 years whose knee pain had been present daily for the previous 3 months. Half of the patients wore a soft neoprene PF brace for a mean of 7.3 hours per day, while the other half did not.

All study participants "had to have at least a score of 40 on a 0-100 mm visual analogue scale (VAS) for nominated aggravating activity likely to originate in the PF joint," Dr. Felson said. "They had to have pain with activities such as stair climbing, kneeling, prolonged sitting or squatting, [and] they also had to have a radiographic KL [Kellgren-Lawrence] score of grade 2 or 3 in the PF joint. That score had to be greater than the KL score for the tibiofemoral compartments. They also had to undergo a clinical exam by a trained physiotherapist to confirm PF joint tenderness."

The researchers performed contrast-enhanced knee MRIs at baseline and at 6 weeks. The primary symptom outcome measure was VAS pain during the patients’ nominated aggravating activity, while the primary structural outcome measure was BML volume in the PF joint as assessed on sagittal precontrast view.

At 6 weeks, Dr. Felson reported that patients in the no-brace group had a mean reduction in their VAS pain of 1.3, compared with a reduction of 18.2 in the braced group, a mean between-group difference of 16.9 that reached statistical significance (P less than .001).

As for PF BML volume, patients in the no-brace group showed a slight increase in volume (mean, 102.7 mm³), while the braced group showed a significant decrease in PF BML volume (mean, –554.9 mm³), for a mean between-group difference of 657.6 mm³ that reached statistical significance (P = .02). "That represents about a 25% decrease in volume," Dr. Felson said.

No differences were observed between the two groups in terms of tibiofemoral BML volume or in synovitis volume.

Dr. Felson acknowledged certain limitations of the study, including its 6-week design. "OA is a long-term chronic disease," he said. "We don’t know what relevance our findings have for longer-term structure changes of the knee."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Patients with osteoarthritis of the knee who wore a patellofemoral brace for 6 weeks experienced a significant reduction in pain and in bone marrow lesion volumes in the patellofemoral region, compared with those who did not wear the brace, a multicenter trial showed.

"There’s a pressing need for nonsurgical intervention for knee osteoarthritis," Dr. David T. Felson said in a press briefing at the annual meeting of the American College of Rheumatology.

"There are no currently approved structure-modifying treatments. This has been a focus of studies that have been testing modifying treatments on hyaline cartilage, which changes slowly, necessitating expensive, long-term, large trials. Even so, mechanopathology such as that caused by malalignment or meniscal tears may make it impossible to protect cartilage in existing OA," he noted.

Dr. Felson, director of the Research in Osteoarthritis in Manchester group at the University of Manchester (England) and professor of medicine at Boston University, went on to note that bone marrow lesions (BMLs) "have been well shown to predict later cartilage loss in that location and correlate with pain and its severity. Recently, we showed that BMLs fluctuate in volume in as little as 6 weeks. Further, one small trial has suggested that zoledronic acid may shrink BMLs and reduce knee pain. That leads us to suggest that BMLs may be a viable treatment target in OA."

The patellofemoral joint "is a major source of knee pain in OA, and there has been little study of the efficacy of PF braces," he continued. "In a body mechanics study, PF bracing has been shown to increase the contact area of the PF joint. It may thereby lower the contact stress and shrink BMLs."

He and his associates set out to determine whether bracing would improve pain and lessen the volume of BMLs in patients with knee OA. They enrolled 126 patients with a mean age of 55 years whose knee pain had been present daily for the previous 3 months. Half of the patients wore a soft neoprene PF brace for a mean of 7.3 hours per day, while the other half did not.

All study participants "had to have at least a score of 40 on a 0-100 mm visual analogue scale (VAS) for nominated aggravating activity likely to originate in the PF joint," Dr. Felson said. "They had to have pain with activities such as stair climbing, kneeling, prolonged sitting or squatting, [and] they also had to have a radiographic KL [Kellgren-Lawrence] score of grade 2 or 3 in the PF joint. That score had to be greater than the KL score for the tibiofemoral compartments. They also had to undergo a clinical exam by a trained physiotherapist to confirm PF joint tenderness."

The researchers performed contrast-enhanced knee MRIs at baseline and at 6 weeks. The primary symptom outcome measure was VAS pain during the patients’ nominated aggravating activity, while the primary structural outcome measure was BML volume in the PF joint as assessed on sagittal precontrast view.

At 6 weeks, Dr. Felson reported that patients in the no-brace group had a mean reduction in their VAS pain of 1.3, compared with a reduction of 18.2 in the braced group, a mean between-group difference of 16.9 that reached statistical significance (P less than .001).

As for PF BML volume, patients in the no-brace group showed a slight increase in volume (mean, 102.7 mm³), while the braced group showed a significant decrease in PF BML volume (mean, –554.9 mm³), for a mean between-group difference of 657.6 mm³ that reached statistical significance (P = .02). "That represents about a 25% decrease in volume," Dr. Felson said.

No differences were observed between the two groups in terms of tibiofemoral BML volume or in synovitis volume.

Dr. Felson acknowledged certain limitations of the study, including its 6-week design. "OA is a long-term chronic disease," he said. "We don’t know what relevance our findings have for longer-term structure changes of the knee."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Patients with osteoarthritis of the knee who wore a patellofemoral brace for 6 weeks experienced a significant reduction in pain and in bone marrow lesion volumes in the patellofemoral region, compared with those who did not wear the brace, a multicenter trial showed.

"There’s a pressing need for nonsurgical intervention for knee osteoarthritis," Dr. David T. Felson said in a press briefing at the annual meeting of the American College of Rheumatology.

"There are no currently approved structure-modifying treatments. This has been a focus of studies that have been testing modifying treatments on hyaline cartilage, which changes slowly, necessitating expensive, long-term, large trials. Even so, mechanopathology such as that caused by malalignment or meniscal tears may make it impossible to protect cartilage in existing OA," he noted.

Dr. Felson, director of the Research in Osteoarthritis in Manchester group at the University of Manchester (England) and professor of medicine at Boston University, went on to note that bone marrow lesions (BMLs) "have been well shown to predict later cartilage loss in that location and correlate with pain and its severity. Recently, we showed that BMLs fluctuate in volume in as little as 6 weeks. Further, one small trial has suggested that zoledronic acid may shrink BMLs and reduce knee pain. That leads us to suggest that BMLs may be a viable treatment target in OA."

The patellofemoral joint "is a major source of knee pain in OA, and there has been little study of the efficacy of PF braces," he continued. "In a body mechanics study, PF bracing has been shown to increase the contact area of the PF joint. It may thereby lower the contact stress and shrink BMLs."

He and his associates set out to determine whether bracing would improve pain and lessen the volume of BMLs in patients with knee OA. They enrolled 126 patients with a mean age of 55 years whose knee pain had been present daily for the previous 3 months. Half of the patients wore a soft neoprene PF brace for a mean of 7.3 hours per day, while the other half did not.

All study participants "had to have at least a score of 40 on a 0-100 mm visual analogue scale (VAS) for nominated aggravating activity likely to originate in the PF joint," Dr. Felson said. "They had to have pain with activities such as stair climbing, kneeling, prolonged sitting or squatting, [and] they also had to have a radiographic KL [Kellgren-Lawrence] score of grade 2 or 3 in the PF joint. That score had to be greater than the KL score for the tibiofemoral compartments. They also had to undergo a clinical exam by a trained physiotherapist to confirm PF joint tenderness."

The researchers performed contrast-enhanced knee MRIs at baseline and at 6 weeks. The primary symptom outcome measure was VAS pain during the patients’ nominated aggravating activity, while the primary structural outcome measure was BML volume in the PF joint as assessed on sagittal precontrast view.

At 6 weeks, Dr. Felson reported that patients in the no-brace group had a mean reduction in their VAS pain of 1.3, compared with a reduction of 18.2 in the braced group, a mean between-group difference of 16.9 that reached statistical significance (P less than .001).

As for PF BML volume, patients in the no-brace group showed a slight increase in volume (mean, 102.7 mm³), while the braced group showed a significant decrease in PF BML volume (mean, –554.9 mm³), for a mean between-group difference of 657.6 mm³ that reached statistical significance (P = .02). "That represents about a 25% decrease in volume," Dr. Felson said.

No differences were observed between the two groups in terms of tibiofemoral BML volume or in synovitis volume.

Dr. Felson acknowledged certain limitations of the study, including its 6-week design. "OA is a long-term chronic disease," he said. "We don’t know what relevance our findings have for longer-term structure changes of the knee."

The researchers stated that they had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Viscosupplementation using hyaluronic acid injections delayed total knee replacement for patients with knee osteoarthritis by up to a median 2.6 years in a retrospective observational study.

The study, involving analysis of a large commercial health insurance claims database (Truven MarketScan), included all 16,529 patients with knee osteoarthritis (OA) who made their first visit to a specialist for the condition in 2008-2011 and who eventually went on to total knee replacement surgery.

Among this group were 4,178 knee OA patients who underwent one or more courses of treatment with any of the Food and Drug Administration–approved injectable hyaluronic acid products. A total of 3,647 of these patients were successfully matched to controls with knee OA who had total knee replacement surgery without any prior hyaluronic acid injections, Dr. Roy D. Altman explained at the annual meeting of the American College of Rheumatology.

The matching process relied upon propensity scores based on age, sex, physician specialty, diagnosis at the first specialist visit, and year. Therein lays a significant study limitation: These variables provide only limited ability to adjust for any differences in baseline knee OA severity that might have existed between patients who did or didn’t receive hyaluronic acid injections. Nor can an observational study establish causality, observed Dr. Altman, professor emeritus of medicine at the University of California, Los Angeles.

That being said, the study demonstrated a strong dose-dependent relationship between viscosupplementation and time from first specialist visit to knee replacement surgery, he noted.

Seventy-nine percent of patients who got hyaluronic acid injections received a single course consisting of either one injection or a series of injections, depending upon the specific product. Those patients experienced a median 233-day increase in the time to surgery, compared with matched controls who didn’t get hyaluronic acid injections.

Moreover, the 16% of viscosupplementation recipients who underwent a second round of treatment further delayed their median time from first specialist visit to total knee replacement by an additional 7 months. And that pattern continued in the relatively small numbers of patients who underwent three or more courses of viscosupplementation: Each round of hyaluronic acid injections brought a roughly 7-month further delay in time to surgery, out to a total of 2.6 years.

The study was sponsored by Johnson & Johnson. Dr. Altman reported having no financial conflicts.

[email protected]

SAN DIEGO – Viscosupplementation using hyaluronic acid injections delayed total knee replacement for patients with knee osteoarthritis by up to a median 2.6 years in a retrospective observational study.

The study, involving analysis of a large commercial health insurance claims database (Truven MarketScan), included all 16,529 patients with knee osteoarthritis (OA) who made their first visit to a specialist for the condition in 2008-2011 and who eventually went on to total knee replacement surgery.

Among this group were 4,178 knee OA patients who underwent one or more courses of treatment with any of the Food and Drug Administration–approved injectable hyaluronic acid products. A total of 3,647 of these patients were successfully matched to controls with knee OA who had total knee replacement surgery without any prior hyaluronic acid injections, Dr. Roy D. Altman explained at the annual meeting of the American College of Rheumatology.

The matching process relied upon propensity scores based on age, sex, physician specialty, diagnosis at the first specialist visit, and year. Therein lays a significant study limitation: These variables provide only limited ability to adjust for any differences in baseline knee OA severity that might have existed between patients who did or didn’t receive hyaluronic acid injections. Nor can an observational study establish causality, observed Dr. Altman, professor emeritus of medicine at the University of California, Los Angeles.

That being said, the study demonstrated a strong dose-dependent relationship between viscosupplementation and time from first specialist visit to knee replacement surgery, he noted.

Seventy-nine percent of patients who got hyaluronic acid injections received a single course consisting of either one injection or a series of injections, depending upon the specific product. Those patients experienced a median 233-day increase in the time to surgery, compared with matched controls who didn’t get hyaluronic acid injections.

Moreover, the 16% of viscosupplementation recipients who underwent a second round of treatment further delayed their median time from first specialist visit to total knee replacement by an additional 7 months. And that pattern continued in the relatively small numbers of patients who underwent three or more courses of viscosupplementation: Each round of hyaluronic acid injections brought a roughly 7-month further delay in time to surgery, out to a total of 2.6 years.

The study was sponsored by Johnson & Johnson. Dr. Altman reported having no financial conflicts.

[email protected]

SAN DIEGO – Viscosupplementation using hyaluronic acid injections delayed total knee replacement for patients with knee osteoarthritis by up to a median 2.6 years in a retrospective observational study.

The study, involving analysis of a large commercial health insurance claims database (Truven MarketScan), included all 16,529 patients with knee osteoarthritis (OA) who made their first visit to a specialist for the condition in 2008-2011 and who eventually went on to total knee replacement surgery.

Among this group were 4,178 knee OA patients who underwent one or more courses of treatment with any of the Food and Drug Administration–approved injectable hyaluronic acid products. A total of 3,647 of these patients were successfully matched to controls with knee OA who had total knee replacement surgery without any prior hyaluronic acid injections, Dr. Roy D. Altman explained at the annual meeting of the American College of Rheumatology.

The matching process relied upon propensity scores based on age, sex, physician specialty, diagnosis at the first specialist visit, and year. Therein lays a significant study limitation: These variables provide only limited ability to adjust for any differences in baseline knee OA severity that might have existed between patients who did or didn’t receive hyaluronic acid injections. Nor can an observational study establish causality, observed Dr. Altman, professor emeritus of medicine at the University of California, Los Angeles.

That being said, the study demonstrated a strong dose-dependent relationship between viscosupplementation and time from first specialist visit to knee replacement surgery, he noted.

Seventy-nine percent of patients who got hyaluronic acid injections received a single course consisting of either one injection or a series of injections, depending upon the specific product. Those patients experienced a median 233-day increase in the time to surgery, compared with matched controls who didn’t get hyaluronic acid injections.

Moreover, the 16% of viscosupplementation recipients who underwent a second round of treatment further delayed their median time from first specialist visit to total knee replacement by an additional 7 months. And that pattern continued in the relatively small numbers of patients who underwent three or more courses of viscosupplementation: Each round of hyaluronic acid injections brought a roughly 7-month further delay in time to surgery, out to a total of 2.6 years.

The study was sponsored by Johnson & Johnson. Dr. Altman reported having no financial conflicts.

[email protected]

SAN DIEGO – The overall proportion of rheumatoid arthritis patients undergoing orthopedic surgery is declining as intensive pharmacologic intervention with agents such as biologics play an increasingly prominent role in the treatment of the inflammatory disease, judging from results from a large, long-term study.

In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat and his associates enrolled 2,342 men and women from RA patient registries in Sweden who filled out questionnaires including visual analog scales for general health and pain, and the Health Assessment Questionnaire (HAQ) in 1997, 2002, 2005, and 2009.

The response rate ranged from 62% to 74%, and the researchers linked responses to Swedish national health registry records to correlate the data with records of inpatient and outpatient surgeries, as well as the use of biologics. They went on to evaluate the incidence rate of orthopedic surgery in three time periods: from 1998-2001 (time period A), 2002-2006 (time period B), and 2007-2011 (time period C).

Dr. Hekmat, a rheumatologist and a PhD fellow at Malmö University, Sweden, reported that between 1998 and 2011 the incidence of all orthopedic procedures performed was 82.3 per 1,000 person-years. Significant declines were observed over the three time periods studied. For example, the incidence of any orthopedic surgery declined from 94.6 per 1,000 person-years in time period A to 82.6 per 1,000 person-years in time period B, and 71.8 per 1,000 person-years in time period C (P less than .001).

A similar association was observed for hip surgery alone (which fell from 27.8 per 1,000 person-years in time period A to 17.6 per 1,000 person-years in time period C; P less than .001). The incidence of orthopedic surgery on small joints such as hands, wrists, feet, and ankles fell from 43.8 per 1,000 person-years in time period A to 30.5 per 1,000 person-years in time period C (P less than .001).

No significant decline occurred in the incidence of knee surgeries performed during the study period. This actually rose slightly from 12.3 per 1,000 person-years in time period A to 12.9 per 1,000 person-years in time period C (P = .759).

Independent predictors of undergoing any orthopedic surgery included being female (hazard ratio 1.50) and having greater disability as measured by the HAQ (HR 1.37).

Dr. Hekmat speculated that the rate of orthopedic surgery was reduced by early intensive treatment in patients with RA, since the time period studied coincided with the increased use of pharmacologic interventions. "In this cohort we are targeting the patients more aggressively," he said. "It’s not wrong to guess that this decline may lead to better [disease] management."

Dr. Hekmat said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – The overall proportion of rheumatoid arthritis patients undergoing orthopedic surgery is declining as intensive pharmacologic intervention with agents such as biologics play an increasingly prominent role in the treatment of the inflammatory disease, judging from results from a large, long-term study.

In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat and his associates enrolled 2,342 men and women from RA patient registries in Sweden who filled out questionnaires including visual analog scales for general health and pain, and the Health Assessment Questionnaire (HAQ) in 1997, 2002, 2005, and 2009.

The response rate ranged from 62% to 74%, and the researchers linked responses to Swedish national health registry records to correlate the data with records of inpatient and outpatient surgeries, as well as the use of biologics. They went on to evaluate the incidence rate of orthopedic surgery in three time periods: from 1998-2001 (time period A), 2002-2006 (time period B), and 2007-2011 (time period C).

Dr. Hekmat, a rheumatologist and a PhD fellow at Malmö University, Sweden, reported that between 1998 and 2011 the incidence of all orthopedic procedures performed was 82.3 per 1,000 person-years. Significant declines were observed over the three time periods studied. For example, the incidence of any orthopedic surgery declined from 94.6 per 1,000 person-years in time period A to 82.6 per 1,000 person-years in time period B, and 71.8 per 1,000 person-years in time period C (P less than .001).

A similar association was observed for hip surgery alone (which fell from 27.8 per 1,000 person-years in time period A to 17.6 per 1,000 person-years in time period C; P less than .001). The incidence of orthopedic surgery on small joints such as hands, wrists, feet, and ankles fell from 43.8 per 1,000 person-years in time period A to 30.5 per 1,000 person-years in time period C (P less than .001).

No significant decline occurred in the incidence of knee surgeries performed during the study period. This actually rose slightly from 12.3 per 1,000 person-years in time period A to 12.9 per 1,000 person-years in time period C (P = .759).

Independent predictors of undergoing any orthopedic surgery included being female (hazard ratio 1.50) and having greater disability as measured by the HAQ (HR 1.37).

Dr. Hekmat speculated that the rate of orthopedic surgery was reduced by early intensive treatment in patients with RA, since the time period studied coincided with the increased use of pharmacologic interventions. "In this cohort we are targeting the patients more aggressively," he said. "It’s not wrong to guess that this decline may lead to better [disease] management."

Dr. Hekmat said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – The overall proportion of rheumatoid arthritis patients undergoing orthopedic surgery is declining as intensive pharmacologic intervention with agents such as biologics play an increasingly prominent role in the treatment of the inflammatory disease, judging from results from a large, long-term study.

In an ongoing population-based study presented at the annual meeting of the American College of Rheumatology, Dr. Korosh Hekmat and his associates enrolled 2,342 men and women from RA patient registries in Sweden who filled out questionnaires including visual analog scales for general health and pain, and the Health Assessment Questionnaire (HAQ) in 1997, 2002, 2005, and 2009.

The response rate ranged from 62% to 74%, and the researchers linked responses to Swedish national health registry records to correlate the data with records of inpatient and outpatient surgeries, as well as the use of biologics. They went on to evaluate the incidence rate of orthopedic surgery in three time periods: from 1998-2001 (time period A), 2002-2006 (time period B), and 2007-2011 (time period C).

Dr. Hekmat, a rheumatologist and a PhD fellow at Malmö University, Sweden, reported that between 1998 and 2011 the incidence of all orthopedic procedures performed was 82.3 per 1,000 person-years. Significant declines were observed over the three time periods studied. For example, the incidence of any orthopedic surgery declined from 94.6 per 1,000 person-years in time period A to 82.6 per 1,000 person-years in time period B, and 71.8 per 1,000 person-years in time period C (P less than .001).

A similar association was observed for hip surgery alone (which fell from 27.8 per 1,000 person-years in time period A to 17.6 per 1,000 person-years in time period C; P less than .001). The incidence of orthopedic surgery on small joints such as hands, wrists, feet, and ankles fell from 43.8 per 1,000 person-years in time period A to 30.5 per 1,000 person-years in time period C (P less than .001).

No significant decline occurred in the incidence of knee surgeries performed during the study period. This actually rose slightly from 12.3 per 1,000 person-years in time period A to 12.9 per 1,000 person-years in time period C (P = .759).

Independent predictors of undergoing any orthopedic surgery included being female (hazard ratio 1.50) and having greater disability as measured by the HAQ (HR 1.37).

Dr. Hekmat speculated that the rate of orthopedic surgery was reduced by early intensive treatment in patients with RA, since the time period studied coincided with the increased use of pharmacologic interventions. "In this cohort we are targeting the patients more aggressively," he said. "It’s not wrong to guess that this decline may lead to better [disease] management."

Dr. Hekmat said that he had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]

SAN DIEGO – Rheumatoid arthritis patients undergoing surgery who stayed on their antirheumatic medication perioperatively didn’t have a higher risk of early postoperative infection compared with those who temporarily stopped treatment before surgery, according to findings from a large national Veterans Affairs study.

Rheumatologists are frequently consulted about this issue. Evidence to guide practice has been scarce, however, and until now many rheumatologists and surgeons have taken a conservative approach, reasoning that the immunosuppressive drugs employed in controlling inflammation in rheumatoid arthritis might also increase the risk of surgical wound infection.

A common practice has been to have RA patients stop their medication a month ahead of elective surgery, or at least two drug half-lives beforehand, then start treatment again roughly a month after the operation, or when the wound has healed. The new Veterans Affairs (VA) study findings suggest this practice may be unnecessary, Dr. Zaki Abou Zahr said at the annual meeting of the American College of Rheumatology.

Dr. Bernard Ng, his senior coinvestigator in the study, added that temporarily stopping antirheumatic agents before surgery may actually be harmful in that it increases the risk of a flare of the RA, which in turn would impede postoperative rehabilitation.

But there is a major caveat regarding the VA study: Participation was restricted to RA patients on only a single conventional disease-modifying antirheumatic drug (DMARD) or biologic agent leading up to surgery. This restriction, imposed to make for a more clear-cut analysis, means that the study results can’t be extrapolated to patients on multidrug therapy. And multidrug therapy is quite common. Indeed, slightly more than half of RA patients in the VA health care system are on combination therapy, most often methotrexate plus a biologic agent, noted Dr. Ng, chief of rheumatology at the VA Puget Sound Health Care System, Seattle.

Dr. Abou Zahr presented the retrospective cohort study involving 6,548 RA patients in VA administrative databases, all of whom were on antirheumatic drug monotherapy prior to surgery. The surgery was of all types, including cardiothoracic, gastrointestinal, vascular, and orthopedic, as well as emergent and elective.

The primary endpoints were the rate of wound infections, both superficial and deep, within 30 days post surgery, and the general infection rate – including pneumonia, sepsis, and urinary tract infections – during the same time frame.

Sixty-two percent of the 1,480 RA patients on a single biologic agent did not stop taking it preoperatively. One key study finding was that neither their postoperative wound infection rate nor their general infection rate differed significantly from rates in patients who temporarily halted their biologic agent. The same held true among the 70% of patients on a single conventional DMARD who did not stop taking their medication preoperatively, according to Dr. Abou Zahr of Baylor College of Medicine, Houston.

Dr. Ng said the investigators plan to extend their work to include RA patients on multiple antirheumatic drugs that they do or don’t temporarily stop when undergoing surgery within the VA system. The researchers also plan to take a close look at patients undergoing specific types of surgery to see if the postoperative infection risk in patients who remain on treatment varies according to their operation.

Dr. Fehmida Zahabi, a rheumatologist from Plano, Tex., who chaired a press conference highlighting the VA study findings, said that while she’d like to see a confirmatory study, "I think we’re getting to the point where we’re saying we should cautiously keep these patients on their medications. That’s what the data suggest."

She noted that before the VA study, the very limited evidence available to guide practice in this area centered on a 12-year-old British randomized trial involving RA patients on methotrexate undergoing elective orthopedic surgery. Those assigned to stop the drug from 2 weeks before surgery to 2 weeks post surgery had significantly more infections, surgical complications, and RA flares within 6 weeks after surgery (Ann. Rheum. Dis. 2001;60:214-7).

As for patients on multidrug therapy who are scheduled for surgery, her inclination until evidence becomes available for guidance is to pare down the regimen preoperatively, while keeping the patient on one or two drugs.

The VA study was funded by the Department of Veterans Affairs. Dr. Abou Zahr and Dr. Ng reported having no conflicts of interest.

[email protected]