This retrospective cohort study compared post-operative infection risk in over 10,900 RA patients undergoing total hip or knee arthroplasty while on one of six biologic DMARDs. It also evaluated how pre-operative glucocorticoid dose affected 30-day hospitalized infection, 1-year prosthetic joint infection, and 30-day readmission.
When counseling an RA patient before total joint arthroplasty, the perioperative conversation should center on glucocorticoid dose — not which biologic they are taking.
The 2017 ACR/AAHKS guideline focuses on withholding biologics for one dosing interval before surgery, but this study shows that glucocorticoids at doses as low as 5–10 mg/day are associated with significantly higher hospitalized infection and readmission rates. Doses above 10 mg/day approximately double the infection risk and significantly elevate 1-year PJI risk.
The practical implication: if a patient's biologic is held perioperatively and their RA flares, the instinct to bridge with steroids carries real infectious risk. Minimizing glucocorticoid dose in the 90 days before surgery should be prioritized alongside the standard biologic hold.
For boards, the key distinction is that biologic class does not independently drive perioperative infection risk in patients on stable chronic therapy — but glucocorticoid dose does, in a dose-dependent fashion. This is the testable concept from this paper.
This retrospective cohort study compared post-operative infection risk in over 10,900 RA patients undergoing total hip or knee arthroplasty while on one of six biologic DMARDs. It also evaluated how pre-operative glucocorticoid dose affected 30-day hospitalized infection, 1-year prosthetic joint infection, and 30-day readmission.
When counseling an RA patient before total joint arthroplasty, the perioperative conversation should center on glucocorticoid dose — not which biologic they are taking.
The 2017 ACR/AAHKS guideline focuses on withholding biologics for one dosing interval before surgery, but this study shows that glucocorticoids at doses as low as 5–10 mg/day are associated with significantly higher hospitalized infection and readmission rates. Doses above 10 mg/day approximately double the infection risk and significantly elevate 1-year PJI risk.
The practical implication: if a patient's biologic is held perioperatively and their RA flares, the instinct to bridge with steroids carries real infectious risk. Minimizing glucocorticoid dose in the 90 days before surgery should be prioritized alongside the standard biologic hold.
For boards, the key distinction is that biologic class does not independently drive perioperative infection risk in patients on stable chronic therapy — but glucocorticoid dose does, in a dose-dependent fashion. This is the testable concept from this paper.