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Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery
  1. Michael D George1,
  2. Joshua F Baker1,2,
  3. Kevin L Winthrop3,
  4. Seth D Goldstein4,5,
  5. E Alemao6,
  6. Lang Chen7,
  7. Qufei Wu1,
  8. Fenglong Xie7,
  9. Jeffrey R Curtis7
  1. 1 Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  2. 2 Rheumatology, Philadelphia VAMC, Philadelphia, Pennsylvania, USA
  3. 3 Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
  4. 4 Surgery, Northwestern University, Evanston, Illinois, USA
  5. 5 Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
  6. 6 Bristol-Myers Squibb, Princeton, New Jersey, USA
  7. 7 Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
  1. Correspondence to Dr Michael D George, University of Pennsylvania, Philadelphia, PA 19104, USA; Michael.George{at}


Objectives The impact of immunosuppression on postoperative outcomes has primarily been studied in patients undergoing joint replacement surgery. We aimed to evaluate the impact of biologics and glucocorticoids on outcomes after other major surgeries.

Methods This retrospective cohort study used Medicare data 2006–2015 to identified adults with rheumatoid arthritis undergoing hip fracture repair, abdominopelvic surgery (cholecystectomy, hysterectomy, hernia, appendectomy, colectomy) or cardiac surgery (coronary artery bypass graft, mitral/aortic valve). Logistic regression with propensity-score-based inverse probability weighting compared 90-day mortality and 30-day readmission in patients receiving methotrexate (without a biologic or targeted synthetic disease-modifying antirheumatic drug (tsDMARD)), a tumour necrosis factor inhibitor (TNFi) or a non-TNFi biologic/tsDMARD <8 weeks before surgery. Similar analyses evaluated associations between glucocorticoids and outcomes.

Results We identified 10 777 eligible surgeries: 3585 hip fracture, 5025 abdominopelvic and 2167 cardiac surgeries. Compared with patients receiving methotrexate, there was no increase in the risk of 90-day mortality or 30-day readmission among patients receiving a TNFi (mortality adjusted OR (aOR) 0.83 (0.67 to 1.02), readmission aOR 0.86 (0.75 to 0.993)) or non-TNFi biologic/tsDMARD (mortality aOR 0.78 (0.49 to 1.22), readmission aOR 1.02 (0.78 to 1.33)). Analyses stratified by surgery category were similar. Risk of mortality and readmission was higher with 5–10 mg/day of glucocorticoids (mortality aOR 1.41 (1.08 to 1.82), readmission aOR 1.26 (1.05 to 1.52)) or >10 mg/day (mortality aOR 1.64 (1.02 to 2.64), readmission aOR 1.60 (1.15 to 2.24)) versus no glucocorticoids, although results varied when stratifying by surgery category.

Conclusions Recent biologic or tsDMARD use was not associated with a greater risk of mortality or readmission after hip fracture, abdominopelvic or cardiac surgery compared with methotrexate. Higher dose glucocorticoids were associated with greater risk.

  • rheumatoid arthritis
  • infections
  • DMARDs (biologic)
  • orthopaedic surgery

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  • Handling editor Josef S Smolen

  • Contributors All authors met criteria for authorship, critically revised the manuscript, gave approval of the final version to be published and agree to be accountable for all aspects of the work related to accuracy or integrity of the results. Specific additional roles included: conception and study design (MG, JFB, KLW, JRC), data acquisition (MG, LC, QW, FX), analysis (MG, JFB, KLW, JRC), interpretation (MG, JFB, KLW, SDG, EA, LC, FX, JRC), and drafting the original manuscript (MG, JFB, JRC).

  • Funding MG is supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases 1K23AR073931-01. JFB is supported by a VA Clinical Science Research and Development Merit Award (I01 CX001703).

  • Competing interests MG has received a research grant from Bristol-Myers Squibb and the National Institutes of Health and consulting fees from AbbVie. JFB has received consulting fees from Bristol-Myers Squibb and Gilead. KLW has received research grants from Pfizer and Bristol-Myers Squibb, and consulting fees from Pfizer, AbbVie, UCB, Lilly, Galapagos, GSK, Roche, and Gilead. EA is an employee of Bristol-Myers Squibb. JRC has received research grants from the Patient Centered Outcomes Research Institute and research grants and consulting fees from Bristol-Myers Squibb, Amgen, AbbVie, Corrona, Janssen, Lilly, Myriad, Pfizer, UCB and Regeneron.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party (Centers for Medicare & Medicaid Services) and are not publicly available. Statistical code is available from the authors upon request.