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• Comment on: Risk of septic arthritis in patients with rheumatoid arthritis and the effect of anti-TNF therapy
  Shigeki Momohara
  Published on: 13 April 2016
• Septic arthritis in patients with rheumatoid arthritis and the effects of anti-TNF therapy.
  David M Grennan
  Published on: 13 April 2016

• Published on: 13 April 2016

  Comment on: Risk of septic arthritis in patients with rheumatoid arthritis and the effect of anti-TNF therapy

  • Shigeki Momohara, Professor
  • Other Contributors:
    • Katsunori Ikari, Takuji Iwamoto

  Dear Editor,

  We read with interest the recent article by Galloway et al. investigating septic arthritis (SA) in rheumatoid arthritis (RA) patients enrolled in the British Society for Rheumatology Biologics Register (BSRBR), who received anti tumour necrosis factor (anti-TNF) therapy.[1]
  The results of their evaluation of data from the BSRBR indicated that anti -TNF therapy for RA is associated with a doubling of t...

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  Dear Editor,

  We read with interest the recent article by Galloway et al. investigating septic arthritis (SA) in rheumatoid arthritis (RA) patients enrolled in the British Society for Rheumatology Biologics Register (BSRBR), who received anti tumour necrosis factor (anti-TNF) therapy.[1]
  The results of their evaluation of data from the BSRBR indicated that anti -TNF therapy for RA is associated with a doubling of the risk for SA, and the authors recommended that physicians and surgeons assessing RA patients take into consideration this potentially life-threatening complication. In addition, the authors addressed the effect of orthopaedic surgery on the risk of SA occurring within 90 days after surgery.

  To date, the results of studies on the association of perioperative anti-TNF therapy and risk for surgical site infections (SSIs) have been conflicting. Some studies on joint surgery in RA patients treated with anti-TNF therapy have failed to demonstrate any significant increase in the incidence of postoperative infection [2-4], while results of other studies have suggested that there were higher complication rates in patients treated with TNF blockers than in patients not treated with blockers.[5, 6] In their evaluation of data from the BSRBR, Galloway et al. concluded that it was reassuring to see no evidence of increased risk of prosthetic joint SA, and that the rate of postoperative joint infection was not significantly influenced by anti-TNF therapy.
  However, the authors reported that the strongest association of the occurrence of SA was with a history of orthopaedic surgery of a large joint at baseline, irrespective of whether SA developed in a prosthetic joint.

  We previously reported that anti-TNF therapy was a likely cause of SSI development in RA patients following major orthopaedic surgery.[7] At that time, we diagnosed SSIs using the criteria for SSIs in the CDC recommendations for Prevention of Surgical Site Infection, 1999.[8] If we only included deep incisional SSI cases in our evaluation of SSIs, TNF blockers were not significant risk factors for acute SSI.
  Therefore, as with the results of the study by Galloway et al., we also agree that the use of anti-TNF therapy does not definitely increase the risk for performing joint surgeries in RA patients. However, because we previously found that the use of TNF-blockers and long RA disease duration were associated with an increased risk of acute SSI in total joint arthroplasties (TJA) when SSI had been diagnosed using the criteria in the CDC recommendations,[9] we believe that TJA should be performed and observed with caution for patients who are treated with anti-TNF therapy.
  If an SSI occurs, especially in a prosthetic joint, patient prognosis is poor, because of difficulties in curing the infection. Periprosthetic joint infection is a devastating complication and is one of the leading causes of morbidity following prosthetic joint replacement with an increased risk of mortality.[10]

  Moreover, whether or not anti-TNF therapy should be discontinued in RA patients undergoing elective orthopaedic surgery should be clarified.
  More data are clearly needed, and additional studies must be performed to determine the effects of interrupting TNF blocker therapy prior to initiating surgical procedures.

  References

  1. Galloway JB, Hyrich KL, Mercer LK, et al. Risk of septic arthritis in patients with rheumatoid arthritis and the effect of anti-TNF therapy: results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis doi:10.1136/ard.2011.152769

  2. Wendling D, Balblanc JC, Brousse A, et al. Surgery in patients receiving anti-tumour necrosis factor alpha treatment in rheumatoid arthritis: an observational study on 50 surgical procedures. Ann Rheum Dis 2005;64(9):1378-1379.

  3. Talwalkar SC, Grennan DM, Gray J, et al. Tumour necrosis factor alpha antagonists and early postoperative complications in patients with inflammatory joint disease undergoing elective orthopaedic surgery. Ann Rheum Dis 2005;64(4):650-651.

  4. den Broeder AA, Creemers MC, Fransen J, et al. Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study. J Rheumatol 2007;34(4):689-695.

  5. Ruyssen-Witrand A, Gossec L, Salliot C,et al. Complication rates of 127 surgical procedures performed in rheumatic patients receiving tumor necrosis factor alpha blockers. Clin Exp Rheumatol 2007;25(3):430-436.

  6. Giles JT, Bartlett SJ, Gelber AC, et al. Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis. Arthritis Rheum 2006;55(2):333-337.

  7. Kawakami K, Ikari K, Kawamura K, et al. Complications and features after joint surgery in rheumatoid arthritis patients treated with tumour necrosis factor-alpha blockers: perioperative interruption of tumour necrosis factor-alpha blockers decreases complications? Rheumatology (Oxford) 2010;49(2):341-347.

  8. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250-278; quiz 279-280.

  9. Momohara S, Kawakami K, Iwamoto T, et al. Prosthetic joint infection after total hip or knee arthroplasty in rheumatoid arthritis patients treated with nonbiologic and biologic disease-modifying antirheumatic drugs. Mod Rheumatol 2011 Feb 12.

  10. Matar WY, Jafari SM, Restrepo C, et al. Preventing infection in total joint arthroplasty. J Bone Joint Surg Am 2010;92 Suppl 2:36-46.

  Conflict of Interest:

  SM has received speaking fees and/or honoraria from Abbott Japan Co., Ltd., Chugai Pharmaceutical Co., Ltd., Eisai Co., Ltd., Mitsubishi Tanabe Pharma Corporation, Santen Pharmaceutical Co., Ltd., and Takeda Pharmaceutical Co., Ltd. KI has received speaking fees and/or honoraria from Abbott Japan Co., Ltd. and Mitsubishi Tanabe Pharma Corporation. The other authors have declared no conflicts of interest.

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  Conflict of Interest:
  None declared.

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• Published on: 13 April 2016

  Septic arthritis in patients with rheumatoid arthritis and the effects of anti-TNF therapy.

  • David M Grennan, Consultant Rheumatologist
  • Other Contributors:
    • Abbas M, Chelliah G, Kay P

  Dear Editor,

  We are interested in the risk of sepsis in prosthetic joints after the use of biologic purposes for RA. We were therefore interested to read the study by 'Galloway et al (1). Galloway and colleagues have used data from the BSR biologics registry to examine the frequency of septic arthritis in anti - TNF treated patients and have found that both anti TNF therapy and previous prosthetic joints increase the...

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  Dear Editor,

  We are interested in the risk of sepsis in prosthetic joints after the use of biologic purposes for RA. We were therefore interested to read the study by 'Galloway et al (1). Galloway and colleagues have used data from the BSR biologics registry to examine the frequency of septic arthritis in anti - TNF treated patients and have found that both anti TNF therapy and previous prosthetic joints increase the risk of septic arthritis in RA subjects. The authors conclude that there is an increased risk of sepsis in prosthetic joints and those patients require careful follow up for septic arthritis after treatment with anti-TNF drugs. This advice is emphasised by a series of patients which we have recently described (2) in which three rheumatoid arthritis patients with prosthetic joints developed sepsis after treatment with anti-TNF drugs between 3 and 20 years post surgery. Thus even patients many years after joint replacements require regular follow up by an appropriately trained health professional if treated with anti-TNF therapies.

  References

  1. Galloway J. Risk of septic arthritis in patients with rheumatoid arthritis and the effect of anti-TNF therapy: results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis 2011;70;1810-1814, doc 101136/and 2011,152769.

  2. Abbas M, Grennan DM, Chelliah EG. A case series of sepsis in prosthetic joints after commencement of anti-TNF therapy in patients with RA, Northwest Rheumatology Club Meeting; 20.5.11.

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  Conflict of Interest:
  None declared.

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