More Biologics, Fewer Surgeries in Rheumatoid Arthritis

Alice Goodman

November 07, 2013

SAN DIEGO — The incidence of joint surgery declined by more than 20% in patients with rheumatoid arthritis (RA) over a 13-year period, according to a large population-based study.

"We proved our hypothesis that the incidence of joint replacement surgery is declining in RA. We assume that the decline is related to better disease control with more aggressive therapy and newer biologics," said lead investigator Korosh Hekmat, MD, a rheumatologist and PhD fellow at Malmö University in Sweden.

"In 1997, there were almost no biologics. By 2005, 30% of patients with RA were using them. Currently about 50% of patients are treated with biologics," Dr. Hekmat explained here at the American College of Rheumatology (ACR) 2013 Annual Meeting.

The population-based study was based on patient registries in Sweden and included 1342 patients diagnosed with RA who reported their pain and general health on a visual analogue scale and answered the Health Assessment Questionnaire in 1997, 2002, 2005, and 2009. Response rates to the questionnaire ranged from 62% to 74%.

These responses were then linked to Swedish registry data for inpatient and outpatient surgery and the use of biologics.

The incidence of any orthopedic surgery went from 94.6 per 1000 person-years in the first period to 71.8 in the third period.

Researchers also observed a decline in the incidence of hip and small joint surgery between the first and third periods. However, knee surgery bucked this trend showing a slight, but not significant, increase.

Table. Incidence of Orthopedic Surgery per 1000 Person-Years

Surgery 1998-2001 2007-20011 P value
Any 94.6 71.8 <.001
Hip 27.8 17.6 <.001
Knee 12.3 12.9 Not significant
Small joint 43.8 30.5 <.001
Large joint 48.5 39.3 =.009


Investigators identified female gender as a predictor of small joint surgery, and greater disability according to the Health Assessment Questionnaire as a predictor of small or large joint surgery.

Commenting on the study, Fehmida Zahabi, MD, from Texas Rheumatology Care, in Piano, Texas, said that the study has major cost implications for healthcare systems.

"The rates of surgery declined from 2002 to 2011— this affects cost. We were treating patients more aggressively over this time period, and we can guess that this decline is due to better management up front," she said.

"We used to refer patients to orthopedic surgeons quite often, but now I see much less need for referral," Dr. Zahabi explained. "Now we need to consider the expense of biologic therapy vis-à-vis the expense of long-term disability, and the financial and personal cost of joint replacement."

Dr. Hekmat and Dr. Zahabi have reported no relevant financial relationships.

ACR 2013 Annual Meeting: Abstract 2682. Presented October 28, 2013.


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