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Rheumatic disorders and surgery

Rheumatic disorders improved post-op risk of fractures increased

Study sought to provide rheumatologists with an update on both the positive and negative effects of bariatric surgery on the rheumatic outcomes reported in the literature

A literature review by researchers looking at the complex relationship between obesity, various rheumatic diseases and bariatric surgery has underscored the need to establish long-term prospective controlled trials evaluate the risk-benefit ratio of bariatric surgery in patients with morbid obesity and rheumatic diseases.

The paper, 'Consequences of bariatric surgery on outcomes in rheumatic diseases', published in Arthritis Research & Therapy, by researchers from the University Orleans, Orleans, France and the University of Balamand, EL-Koura, Lebanon, sought to provide rheumatologists with an update on both the positive and negative effects of bariatric surgery on the rheumatic outcomes reported in the literature.

For their study, the investigators examined all relevant studies (case reports were not selected) that included the following search terms used in various combinations: bariatric surgery, osteoporosis, osteoarthritis (OA), rheumatoid arthritis (RA), psoriatic arthritis, gout, adipokines, fracture, bone densitometry, obesity and low back pain.

BMD and fracture risk

The researchers note that there is substantial evidence that bariatric surgery procedures are associated with a negative effect on bone health and several prospective studies have shown that bariatric surgery is associated not only with an increase in bone turnover markers, in favour of an increased resorption, but also with a decrease in bone mineral density (BMD). An increase in bone turnover markers and in BMD loss is associated with malabsorptive procedures and skeletal fragility. However, a study conducted in the UK (Cooper C, et al. Risk of fracture after bariatric surgery in the United Kingdom: population based, retrospective cohort study. BMJ. 2012;345), found no significant increase in fracture risk associated with bariatric surgery. Nevertheless, several studies have reported that malabsorptive procedures have been shown to be associated with an increased risk of fracture and that the risk of fracture after bariatric surgery might be bone site specific with a higher susceptibility for upper limb fracture.

Osteoarthritis

Obesity is a known risk factors of osteoarthritis (OA), particularly at the knee joint. A study by Poolman et al (Effects of bariatric surgery for knee complaints in (morbidly) obese adult patients: a systematic review: bariatric surgery for knee complaints. Obes Rev. 2015;16(2):161–70.) revealed that surgery was associated with an antalgic effect in individuals with symptomatic knee OA, however, the lack of data were highlighted by the authors.

Rheumatoid arthritis

Sparks et al (Impact of bariatric surgery on patients with rheumatoid arthritis: bariatric surgery and RA. Arthritis Care Res. 2015;67(12):1619–26.) examined RA outcomes in RA patients after bariatric surgery. In total, 53 RA patients were assessed on RA characteristics and disease activity following a bariatric surgery procedure (RYGB, 81%) with a mean ± SD time of most recent follow-up visit of 5.8±3.2 years after surgery. Twelve months following surgery, 6% vs 57% at baseline had moderate to high disease activity (p<0.001) and 74% of RA patients vs 26% at baseline were in remission at the most recent follow-up visit.

Psoriatic arthritis

Two large prospective studies Gelfand et al (Obesity and the risk of psoriatic arthritis: a population-based study. Ann Rheum Dis. 2012;71(8):1273–7) and Qureshi et al (Obesity and risk of incident psoriatic arthritis in US women. Ann Rheum Dis. 2012;71(8):1267–72) has shown that obesity is not only a comorbid condition in Psoriatic arthritis (PsA) but a real risk factor – and obesity might play a role in the severity of the PsA and interfere with the capacity to achieve and sustain minimal disease activity.

Reddy et al (Clinical improvements in psoriasis and psoriatic arthritis with surgical weight loss [abstract]. Arthritis Rheumatol. 2015;67(Suppl 10)), conducted one of the few studies assessing the effects of surgical weight loss on 86 patients with psoriasis and 21 with PsA. In the 21 patients who had PsA, disease severity rating decreased from 6.4 to 4.5 (p=0.01); a more clinically relevant decrease was observed in patients with the worst disease (8.2 vs 4.8) (p < 0.01). The authors noted that, “The sample size in this study did not permit any definitive conclusions although results are encouraging.”

A study in Denmark by Skov et al (Incidence and prognosis of psoriasis and psoriatic arthritis in patients undergoing bariatric surgery. JAMA Surg. 2017;152(4):344), investigating the first occurrence of PsA in patients treated with gastric bypass or gastric banding, revealed that a decreased risk of PsA (adjusted HR, 0.29; 95% CI 0.12–0.71) was found in patients who underwent a gastric bypass, but this was not observed in patients following gastric banding (adjusted HR, 0.53; 95% CI 0.08–3.56).

“Bariatric procedures have deleterious effects on bone metabolism, and there is a great body of evidence showing that this can lead to an increase in fracture risk, particularly in patients operated with malabsorptive techniques,” the authors concluded. “The present narrative literature review aimed to provide some new insights into the complex relationship between obesity and various rheumatic diseases and underlines the need to conduct additional trials, if possible long-term prospective controlled trials, to fully assess the risk-benefit ratio of bariatric surgery in morbidly obese patients with rheumatic diseases.”

To access this paper, please click here

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