“The increased infection risk in individuals on TNF-alpha inhibitors was expected and our study confirmed the suspicion that the risk is significantly elevated when surgery is performed during the influence of these drugs,” says Dr. Kramers-de Quervain. “Rather surprising was the finding of the increased infection risk in individuals treated with more than one conventional DMARD compared to monotherapy [treatment with one DMARD alone].” Conventional, or traditional, DMARDs such as methotrexate are generally thought to be safe to continue prior to surgery.

But Dr. Bongartz suggests the increase in infection risk found with the use of multiple DMARDs “may be a sign of more severe disease with more difficult surgeries” and doesn’t necessarily indicate that the medications themselves increase a patient’s susceptibility to infection.

The results of this study contradict those of a study presented at the American College of Rheumatology’s annual meeting in October, in which researchers analyzed Veterans’ Affairs databases and found that people taking conventional DMARDs and/or biologics (types of drugs that include TNF inhibitors and other medications) did not have an increased risk of infection after orthopaedic surgery. That study, which has yet to be published, was relatively small and did not distinguish among different types of RA medications or different types of surgeries, making it difficult to draw broad conclusions.

Patients who are considering stopping their arthritis medication prior to scheduled surgery must carefully weigh the benefits against the risk of a disease flare. “The decision … is highly complex and should involve the patient, rheumatologist and orthopaedic surgeons,” says Dr. Bongartz.

“Several factors will be of importance, such as the type of rheumatic disease, the extent of the disease, current disease control, possible risk of a disease flare, possible consequences of a flare – which can be much more serious in a patient with extra-articular [outside the joint] manifestations such as somebody with vital organ involvement – type of surgery, history of previous infections, et cetera,” says Dr. Bongartz.

The study authors note, “when postoperative infection occurred, the patient had to undergo several subsequent surgeries, sometimes more than five, and spend a long time in the hospital, particularly with infections at the site of an arthroplasty [joint repair or replacement]. This shows that even a small decrease in the risk of postoperative infection would be of great benefit to the patient and reduce the associated costs of treatment.”