Increase of body mass index in a tight controlled methotrexate-based strategy with prednisone in early rheumatoid arthritis: Side effect of the prednisone or better control of disease activity?

The Effects of Treatment on Body Mass Index in Giant Cell Arteritis: A Post Hoc Analysis of the GiACTA Trial

Introduction

Giant cell arteritis (GCA) requires treatment with high-dose, long-term glucocorticoids (GCs), and tocilizumab is often used early in the treatment paradigm. Weight gain, which is associated with morbidity and mortality, is a major concern for patients, though the factors that contribute to changes in body mass index (BMI) throughout the treatment of GCA are poorly understood.

Methods

We analyzed GCA patients enrolled in the GiACTA (Tocilizumab in Giant Cell Arteritis) trial. We used univariable and multivariable mixed-effects modeling to examine the association between changes in BMI and cumulative GC dose, disease status at baseline (newly diagnosed versus relapsing), randomization to tocilizumab, and disease flares.

Results

A total of 250 patients were included (75% females, mean age 69 years). The mean ± SD BMI change over 52 weeks was 1.18 ± 1.98 kg/m². On multivariable analysis, cumulative prednisone dose at 52 weeks was independently associated with BMI increase (β = 0.94 kg/m² for 0–1 g exposure; β = 1.40 kg/m² for ≥ 4 g exposure; p for trend < 0.001). Relapsing disease at baseline (β = − 0.42 kg/m² compared to those with newly diagnosed disease; p = 0.002) and flares over 52 weeks in newly diagnosed patients (β = − 0.18 kg/m² per flare; p = 0.03) were independently associated with lower BMI increase.

Conclusions

Cumulative prednisone exposure is associated with increased BMI in GCA patients. In those with newly diagnosed disease, effective disease control regardless of the treatment used also contributes to BMI increase. Modest weight gain may be an indicator of adequate treatment response.

Long-term systemic glucocorticoid therapy and weight gain: a population-based cohort study

OBJECTIVES

To describe the variation in weight gain in people chronically exposed to systemic glucocorticoids in primary care and to identify the risk factors for weight gain.

METHODS

Data were analysed from the British database, The Health Improvement Network. Body weight variations of individuals prescribed systemic glucocorticoids for at least 3 months at a mean dose ≥10 mg/day were described. The risk factors associated with weight gain ≥10% of the usual weight were assessed.

RESULTS

A total of 31 516 adults prescribed glucocorticoids and 26 967 controls were included in the study. During glucocorticoid exposure, only 12 475 (39.6%) individuals gained >2 kg compared with their usual weight. Younger women were more likely to gain weight (mean weight gain in 18-39-year-old glucocorticoid-exposed women: 3.6 kg (s.d. 8.6) compared with 2 kg (s.d. 7.3) in the control group; the absolute mean difference was 1.6 kg (95% CI 0.9, 2.2; P < 0.001). Weight gain ≥10% of the usual weight was observed in 10.2% (n = 3208) of those chronically exposed to glucocorticoids. Women, younger people, those living in areas of higher deprivation, smokers, those on higher doses of the drug and those previously exposed to glucocorticoids were at higher risk. The risk was lower in people prescribed glucocorticoids for an inflammatory condition when compared with asthma or chronic obstructive pulmonary disease.

CONCLUSION

After taking into account usual weight rather than weight just before glucocorticoid initiation and the natural history of weight variation, the amount of weight gain induced by systemic glucocorticoids as prescribed in primary care is less than usually thought.

CLINICAL TRIAL REGISTRATION

18THIN081.

Weight Fluctuation and the Risk of Cardiovascular Events in Patients with Rheumatoid Arthritis

PURPOSE

Fluctuations in weight have been linked to cardiovascular (CV) outcomes in the general population. We evaluated whether weight fluctuation was independently predictive of CV events in patients with rheumatoid arthritis (RA).

METHODS

We studied patients with RA from the Corrona registry. Weight change was categorized as loss of ≥10%, loss of 5-10%, stable, gain of 5-10%, and gain of ≥10%. We also categorized patients by quintile of variability in weight in prior observation periods. Cox proportional hazard models explored independent associations between time-varying weight change and weight variability and risk of CV events before and after adjusting for CV risk factors, RA disease features, and disability.

RESULTS

Among 31,381 participants, those that lost or gained 10% of their weight had greater disease activity, worse physical function, and were more likely to smoke, have diabetes, use corticosteroids, and be disabled. In adjusted models, a greater risk of CV events was observed in those that experienced 10% weight loss [HR: 1.18 (1.03,1.36) p=0.02] or weight gain [HR 1.20 (1.04,1.38) p=0.01]. The association between weight change and CV events was stronger among participants with BMI <25 kg/m² for 10% weight loss [HR: 1.34 (1.08,1.66) p=0.001] and 10% weight gain [1.74 (1.41,2.24) p<0.001]. Patients with greater variability in weight had a higher risk of CV events.

CONCLUSIONS

Recent changes and high variability in weight predict CV events in RA, particularly among thin patients. Further study is necessary to determine if weight fluctuation has adverse cardiometabolic consequences that are independent of other risk factors.

Effect of Body Mass Index on the Disease Activity of Patients With Rheumatoid Arthritis in a Gender-Specific Manner and the Association of Respective Serum C-Reactive Protein Levels With the Body's Inflammatory Status

Background Current literature evaluating the effect of high body mass index (BMI) on the disease activity of patients with rheumatoid arthritis (RA) is mixed as some studies have shown a positive, linear relationship between BMI and disease activity while others have demonstrated an inverse correlation. Through this study, we have expanded the effect of BMI on disease activity in patients with RA. We have further expanded on whether BMI influences the disease activity depending on the gender being studied. Finally, we have studied whether there is a correlation between high BMI values and rising C-reactive protein (CRP) levels. Methodology This cross-sectional study was conducted at the Outpatient Clinical Department of Buffalo Rheumatology. The study was ethically approved by the Catholic Health Institutional Review Board. A total number of 451 patients' clinical data was selected based on inclusion/exclusion criteria. The patients were divided into different BMI categories based on the guidelines of national obesity education initiative of the national heart, lung, and blood Institute. The following clinical parameters were studied: BMI, serum CRP level, and disease activity through routine assessment of patient index data questionnaire 3 (RAPID3). The minimum sample size (n = 358) was calculated via the world health organization sample size calculator. All data were entered and analyzed through Statistical Package for the Social Sciences (SPSS), version 16.0 (IBM Corp., Armonk, NY). Results Our study sample included 98 males and 353 females (22% and 78%, respectively). Collective data for both the genders showed significantly increased disease activity in RA patients with high BMI values (p = 0.04). When the data sets were categorized according to the two genders, it was noted that the aforementioned results remain significant for the females only (p = 0.02 for females and p = 0.57 for males). At all BMI values, mean RAPID3 scoring remained significantly higher for females as opposed to their male counterparts (p = 0.006). Mean serum CRP levels increased linearly with increasing BMI (p < 0.001); however, for the underweight patient population, mean CRP levels were the highest as compared to normal weight, overweight, moderately obese, and severely obese patients. Conclusion We conclude that the association between the BMI and the severity of disease remains elusive. High BMI values increase the risk of a pro-inflammatory state of the body due to higher serum CRP levels. Estimating the clinically significant benefit of this theory would require a large-scale clinical trial that would highlight the role of losing weight in improving the patients' quality of life, pain control, and mortality.

Cachexia in patients with rheumatoid arthritis: a cohort study

BACKGROUND

Rheumatoid arthritis (RA) is an inflammatory disease that leads to altered body composition. The loss of lean mass with a preservation or increase in fat mass has been termed rheumatoid cachexia (RC), to contrast with classic cachexia, which is characterized by severe weight loss. There are limited data on the prevalence and progression of cachexia in RA over time, as well as on associated factors. Our aim was to determine the prevalence of cachexia and to determine associations with potential factors.

METHODS

This prospective cohort study recruited consecutively patients diagnosed with RA and followed for 1 year. The assessments were performed: clinical features, body composition, and physical function. RC and classic cachexia were assessed by several established diagnostic criteria. The pairwise Student's t test, Chi-square test, and GEE were performed (accepted at p ≤ 0.05).

RESULTS

Of 90 patients recruited, 81 completed the study. Most patients were women (88.9%), and the mean age was 56.5 ± 7.3 years. At baseline, the median DAS28-CRP was 3.0 (IQR, 1.0-3.0), 13.3-30.0% of the included patients had RC, while none met criteria for classic cachexia. The prevalence of cachexia did not change after 12 months. Disease activity status and treatment with biologic disease-modifying antirheumatic drugs were significantly associated with changes on body composition and physical function (p < 0.05).

CONCLUSIONS

In this cohort, RC was common, while classic cachexia was absent. Disease activity and use of biologic therapies were associated with changes on body composition and physical function, underscoring the importance of aiming for remission when treating RA.

How Do Glucocorticoids Used in Rheumatic Disease Affect Body Weight? A Narrative Review of the Evidence

Glucocorticoids (GCs) are widely used to effectively treat inflammatory disease, but GCs have a number of recognized side effects. Patients and clinicians view these side effects differently, with clinicians most concerned with serious side effects such as osteoporosis and diabetes mellitus. Consequently, these side effects are well researched with clinical guidelines and recommendations. A side effect of particular concern to patients is weight gain, but this topic has not been well researched, and consequently clinicians find it difficult to provide patients with accurate information about the potential of weight gain. The aim of this review is to provide an overview of GC use specifically in rheumatic disease, patient views on GC therapy, and GC-induced weight gain. We will discuss the evidence, including the extent and the impact of weight gain on the patient, and highlight areas that warrant further investigation.

Modeling of cumulative effects of time-varying drug exposures on within-subject changes in a continuous outcome

An accurate assessment of the safety or effectiveness of drugs in pharmaco-epidemiological studies requires defining an etiologically correct time-varying exposure model, which specifies how previous drug use affects the outcome of interest. To address this issue, we develop, and validate in simulations, a new approach for flexible modeling of the cumulative effects of time-varying exposures on repeated measures of a continuous response variable, such as a quantitative surrogate outcome, or a biomarker. Specifically, we extend the linear mixed effects modeling to estimate how past and recent drug exposure affects the way individual values of the outcome change throughout the follow-up. To account for the dosage, duration and timing of past exposures, we rely on a flexible weighted cumulative exposure methodology to model the cumulative effects of past drug use, as the weighted sum of past doses. Weights, modeled with unpenalized cubic regression B-splines, reflect the relative importance of doses taken at different times in the past. In simulations, we evaluate the performance of the model under different assumptions concerning (i) the shape of the weight function, (ii) the sample size, (iii) the number of the longitudinal observations and (iv) the intra-individual variance. Results demonstrate the accuracy of our estimates of the weight function and of the between- and within-patients variances, and good correlation between the observed and predicted longitudinal changes in the outcome. We then apply the proposed method to re-assess the association between time-varying glucocorticoid exposure and weight gain in people living with rheumatoid arthritis.

A systematic review of the association of obesity with the outcomes of inflammatory rheumatic diseases

This was a systematic review of the literature on the association between obesity and the outcome of inflammatory rheumatic diseases. We conducted a literature search using PubMed®, Embase and PsycINFO®. Articles were classified into three categories based on the effects of obesity on the outcomes of inflammatory rheumatic diseases. The subject population, country, type of studies, number of patients, measurement of obesity and outcomes assessed were presented. Quality was appraised using Kmet et al's criteria. 4,331 articles were screened and 60 were relevant to the objective. Obesity had a negative, positive and neutral association with outcomes of inflammatory rheumatic diseases in 38 (63.3%) studies with 57,612 subjects, 11 (18.3%) studies with 3,866 subjects, and 11 (18.3%) studies with 3,834 subjects, respectively. In most studies, the disease population had been diagnosed with rheumatoid arthritis (RA). Tumour necrosis factor-α inhibitors were mostly associated with negative outcomes. More studies examining subjects outside Europe and North America and diseases other than RA are warranted.

Prevalence of rheumatoid cachexia in rheumatoid arthritis: a systematic review and meta-analysis

BACKGROUND

Low muscle mass occurs in patients with rheumatoid arthritis without weight loss; this condition is referred as rheumatoid cachexia. The aim of the current study was to perform a systematic review with meta-analysis to determine the rheumatoid cachexia prevalence.

METHODS

A systematic review with meta-analysis of observational studies published in English, between 1994 and 2016, was conducted using MEDLINE (via PubMed) and other relevant sources. Search strategies were based on pre-defined keywords and medical subject headings. The methodological quality of included studies was assessed using the Newcastle-Ottawa Scale. Meta-analysis was used to estimate the prevalence, and because studies reported different methods and criteria to estimate body composition and prevalence of rheumatoid cachexia, subgroup analyses were performed. Meta-regression adjusted for the 28-joint disease activity score and disease duration (years) was performed (significance level at P ≤ 0.05).

RESULTS

Of 136 full articles (one duplicate publication) screened for inclusion in the study, eight were included. The estimated overall prevalence of rheumatoid cachexia was 19% [95% confidence interval (CI) 07-33%]. This prevalence was 29% (95% CI 15-46%) when body composition was measured by dual-energy X-ray absorptiometry. When the diagnostic criteria were fat-free mass index below the 10th percentile and fat mass index above the 25th percentile, rheumatoid cachexia prevalence was 32% (95% CI 14-52%). The 28-joint disease activity score and disease duration had no influence on the estimated prevalence of rheumatoid cachexia (P > 0.05). Most studies were rated as having moderate methodological quality.

CONCLUSIONS

Meta-analysis showed a prevalence of rheumatoid cachexia of 15-32%, according to different criteria, demonstrating that this condition is a frequent comorbidity of rheumatoid arthritis. To better understand its clinical impact, more studies using standardized definitions and prospective evaluations are urgently needed.

Effect of Disease Activity, Glucocorticoid Exposure, and Rituximab on Body Composition During Induction Treatment of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

OBJECTIVE

We investigated the relationships between glucocorticoid use, disease activity, and changes in body mass index (BMI) in patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

We analyzed AAV patients enrolled in the Rituximab in AAV trial. Glucocorticoid use, BMI, and disease activity were measured regularly during the trial period. We performed mixed-effects regressions to examine the associations of time-dependent cumulative average glucocorticoid use and disease activity with changes in BMI over time, while adjusting for potential confounders.

RESULTS

The mean ± SD baseline BMI of the 197 patients enrolled was 28.8 ± 6.3 kg/m² . Patients with newly diagnosed AAV tended to have a lower mean ± SD BMI than those with relapsing disease (28.0 ± 5.7 kg/m² versus 29.6 ± 6.8 kg/m² ) and higher disease activity (mean ± SD Birmingham Vasculitis Activity Score for Wegener's Granulomatosis 8.7 ± 3.3 versus 7.4 ± 2.7). The most significant change in BMI occurred during the first 6 months of the trial (mean ± SD increase of 1.1 ± 2.2 kg/m² ; P < 0.0001). Disease activity improvement, glucocorticoid exposure, and randomization to rituximab were each independently associated with an increase in BMI (P < 0.001 for all analyses).

CONCLUSION

Our findings suggest that changes in BMI, as well as glucocorticoid exposure, are independently associated with improvements in disease activity in AAV. Rituximab may also have effects on BMI independent of its impact on disease activity.

Changes in Body Mass Related to the Initiation of Disease-Modifying Therapies in Rheumatoid Arthritis

OBJECTIVE

Unintentional weight loss is important and can be predictive of long-term outcomes in patients with rheumatoid arthritis (RA). This study was undertaken to assess how primary therapies for RA may influence changes in body mass index (BMI) in RA patients from a large administrative database.

METHODS

Unique dispensing episodes of methotrexate, prednisone, leflunomide, and tumor necrosis factor inhibitors (TNFi) administered to RA patients were identified from the US Department of Veterans Affairs pharmacy databases. Values for C-reactive protein (CRP) level and BMI closest to the time point within 30 days of the treatment course start date and at follow-up time points were linked. Missing laboratory values were imputed. Weight loss was defined as a decrease in BMI of >1 kg/m(2) . Regression models were used to evaluate changes in BMI during each drug treatment as compared to treatment with methotrexate. To assess the impact of confounding by indication, propensity scores for use of each drug were incorporated in analyses using matched-weighting techniques.

RESULTS

In total, 52,662 treatment courses in 32,859 RA patients were identified. At 6 months from the date of prescription fill, weight gain was seen among patients taking methotrexate, those taking prednisone, and those taking TNFi. On average, compared to methotrexate-treated patients, prednisone-treated patients had significantly more weight gain, while leflunomide-treated patients demonstrated weight loss. In multivariable models, more weight loss (β = -0.41 kg/m(2) , 95% confidence interval [95% CI] -0.46, -0.36; P < 0.001) and a greater risk of weight loss (odds ratio 1.73, 95% CI 1.55, 1.79; P < 0.001) were evident among those receiving leflunomide compared to those receiving methotrexate. Treatment with prednisone was associated with greater weight gain (β = 0.072 kg/m(2) , 95% CI 0.042, 0.10; P < 0.001). These associations persisted in analyses adjusted for propensity scores and in sensitivity analyses.

CONCLUSION

Leflunomide is associated with significantly more, but modest, weight loss, while prednisone is associated with greater weight gain compared to other therapies for RA.

Characteristics of Hearts at Necropsy in Patients Treated Chronically With Prednisone (The Corticosteroid Heart)

It is known that long-term corticosteroid therapy increases fatty deposits in several human tissues. To quantify the quantity of fatty deposits in the heart in patients on prednisone, we examined the heart at necropsy in 37 patients who had received long-term corticosteroid therapy (prednisone in 34) and compared certain findings in them to those in 194 (steroid-naïve) patients also studied at necropsy at Baylor University Medical Center, Dallas, in a 3-year period (2013, 2014, and 2015). Significant differences between the 2 groups were found in age, gender, and frequency of coronary artery disease but not in body mass index, frequency of massive cardiac adiposity, heart weight, or frequency of systemic hypertension or diabetes mellitus. Furthermore, no significant differences were observed in the patients taking ≤20 mg versus those taking >20 mg daily of prednisone. In conclusion, this study observed no significant differences in body mass index, frequency of cardiac adiposity (floating heart), heart weight, or frequencies of systemic hypertension or diabetes mellitus in the patients receiving or not receiving prednisone for a long term, but the prednisone-treated patients were younger, more often women, and had a lower frequency of severe narrowing of ≥1 major coronary arteries.

The Obesity Epidemic and Consequences for Rheumatoid Arthritis Care

With the prevalence of obesity increasing dramatically worldwide over the past several decades, an increasing body of literature has examined the impact of obesity in the context of rheumatoid arthritis (RA). Epidemiologic studies suggest that obesity may be associated with a modestly increased risk for the development of RA, although these studies have shown conflicting results. Among patients with established RA, obesity has been observed to be associated with greater subjective measures of disease activity and poor treatment response, but also with a decreased risk of joint damage and lower mortality. A comprehensive evaluation of the influence of obesity on the measurement of disease, response to therapies, and long-term prognosis is critical in order to understand these observations. This review therefore focuses on recent observations, potential explanations for these findings, and implications for clinicians and investigators caring for and studying patients with RA.

Balancing benefits and risks of glucocorticoids in rheumatic diseases and other inflammatory joint disorders: new insights from emerging data. An expert consensus paper from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO)

PURPOSE

This consensus review article considers the question of whether glucocorticoid (GC) therapy is still relevant in the treatment of rheumatic diseases, with a particular focus on rheumatoid arthritis (RA), and whether its side effects can be adequately managed. Recent basic and clinical research on the molecular, cellular and clinical effects of GCs have considerably advanced our knowledge in this field. An overview of the subject seems appropriate.

METHODS

This review is the result of a multidisciplinary expert working group, organised by European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis. The recent literature was surveyed and the salient evidence synthetized.

RESULTS

The pathophysiological basis of RA (and other inflammatory rheumatic diseases) now strongly implicates the adaptive immune system in addition to innate mechanisms. The molecular effect of GCs and differential GC sensitivity is better understood, although exploiting this knowledge is still in its infancy. The newer treatment strategies of early and aggressive control of RA have gr eatly improved clinical outcomes, but improvements are still possible. Newer targeted anti-inflammatory drugs have made an important impact, yet they too are associated with numerous side effects.

DISCUSSION

Short durations of moderate doses of GCs are generally well tolerated and have a positive benefit/risk ratio. Patients should be assessed for fracture risk and bone preserving agents and be prescribed calcium and vitamin D supplementation.

CONCLUSIONS

Within a strategy of a disease modifying approach to inflammatory disease, combination therapy including a GC is effective approach.

Association between body composition and disease activity in rheumatoid arthritis. A systematic review

BACKGROUND

Reports regarding the association between body composition and inflammatory activity in rheumatoid arthritis (RA) have consistently yielded contradictory results.

OBJECTIVE

To perform a systematic review on the association between overweight/obesity and inflammatory activity in RA.

METHODS

FAST approach: Article search (Medline, EBSCO, Cochrane Library), followed by abstract retrieval, full text review and blinded assessment of methodological quality for final inclusion. Because of marked heterogeneity in statistical approach and RA activity assessment method, a meta-analysis could not be done. Results are presented as qualitative synthesis.

RESULTS

One hundred and nineteen reports were found, 16 of them qualified for full text review. Eleven studies (8,147 patients; n range: 37-5,161) approved the methodological quality filter and were finally included. Interobserver agreement for methodological quality score (ICC: 0.93; 95% CI: 0.82-0.98; P<.001) and inclusion/rejection decision (k 1.00, P>.001) was excellent. In all reports body composition was assessed by BMI; however a marked heterogeneity was found in the method used for RA activity assessment. A significant association between BMI and RA activity was found in 6 reports having larger mean sample size: 1,274 (range: 140-5,161). On the other hand, this association was not found in 5 studies having lower mean sample size: 100 (range: 7-150).

CONCLUSIONS

The modulation of RA clinical status by body fat mass is suggested because a significant association was found between BMI and inflammatory activity in those reports with a trend toward higher statistical power. The relationship between body composition and clinical activity in RA requires be approached with further studies with higher methodological quality.

Predictors of longterm changes in body mass index in rheumatoid arthritis

OBJECTIVE

Low body mass index (BMI) is a risk factor for poor longterm outcomes in rheumatoid arthritis (RA). The purpose of this study was to identify factors associated with longterm changes in BMI.

METHODS

Subjects with RA from the Veterans Affairs (VA) Rheumatoid Arthritis (VARA) Registry (n = 1474) were studied. Information on inflammatory markers, presence of erosions, and smoking status were extracted from the VARA database. BMI was extracted from VA electronic medical records within 14 days of each visit date. VA pharmacy records were queried to identify prescriptions for specific RA therapies within 1 month of the visit date. We used robust generalized estimating equations marginal regression models to calculate independent associations between clinical variables and BMI over time. Similar models determined predictors of change in weight and risk of weight loss over the subsequent study observation period.

RESULTS

Increasing age, active smoking, and the presence of erosions at baseline were associated with lower BMI. Weight decreased over time among older adults. Factors associated with greater reductions in BMI over time and a greater risk of weight loss were higher inflammatory markers, smoking, older age, higher BMI, and less subsequent improvement in inflammation. Methotrexate use was associated with a lower risk of weight loss. The use of prednisone or anti-tumor necrosis factor therapies was not associated with change in BMI or the risk of weight loss independent of other factors.

CONCLUSION

Greater age, greater inflammatory activity, and active smoking are associated with greater weight loss in RA over time.

Safety of glucocorticoids in rheumatoid arthritis: evidence from recent clinical trials

Glucocorticoids are one of the most effective treatments for rheumatoid arthritis, with well-established efficacy in controlling the disease symptoms and structural progression. Fears regarding their toxicity are reflected in common recommendations for the use of the lowest possible dose for the shortest possible time. We herein review toxicity data obtained in randomized clinical trials of low-dose glucocorticoid in rheumatoid arthritis, given that observational studies cannot guarantee the avoidance of bias by indication. Seven eligible randomized controlled trials were identified. These publications do not identify any strong signal of relevant toxicity of glucocorticoid in doses of up to 10 mg of prednisone equivalent/day for up to 2 years. However, the quantity (1,100 patient years of exposure) and especially the quality of evidence are too limited to establish conclusions. A large prospective trial dedicated to the toxicity of low-dose glucocorticoid is dearly needed. Meanwhile, adherence to recommendations on standardized methodologies for the registration and report of glucocorticoid adverse events is essential to improve our knowledge and competence in the best management of these important medications.

Glucocorticoids in early rheumatoid arthritis: are the benefits of joint-sparing effects offset by the adverse effect of osteoporosis? the effects on bone in the utrecht study and the CAMERA-II study

This paper reviews the clinical effects on bone of 10 mg of prednisone daily in early rheumatoid arthritis, given for 2 years in the Utrecht Study and in the second CAMERA (Computer- Assisted Management in Early Rheumatoid Arthritis) Study, and addresses the question whether there were joint-sparing effects and whether these were offset by adverse effects, especially osteoporosis. We conclude that a 2-year adjunct treatment with 10 mg of prednisone daily increases the benefits of disease-modifying antirheumatic drug therapy and has joint-sparing properties, even if added to the tight control methotrexate-based strategy aiming for remission. Importantly, with good control of inflammation and adequate use of calcium, vitamin D and bisphosphonates - according to national or international guidelines - steroid-induced osteoporosis is rare over 2 years.

The value of glucocorticoid co-therapy in different rheumatic diseases--positive and adverse effects

Glucocorticoids play a pivotal role in the management of many inflammatory rheumatic diseases. The therapeutic effects range from pain relief in arthritides, to disease-modifying effects in early rheumatoid arthritis, and to strong immunosuppressive actions in vasculitides and systemic lupus erythematosus. There are multiple indications that adverse effects are more frequent with the longer use of glucocorticoids and use of higher dosages, but high-quality data on the occurrence of adverse effects are scarce especially for dosages above 10 mg prednisone daily. The underlying rheumatic disease, disease activity, risk factors and individual responsiveness of the patient should guide treatment decisions. Monitoring for adverse effects should also be tailored to the patient. Continuously balancing the benefits and risks of glucocorticoid therapy is recommended. There is an ongoing quest for new drugs with glucocorticoid actions without the potential to cause harmful effects, such as selective glucocorticoid receptor agonists, but the application of a new compound in clinical practice will probably not occur within the next few years. In the meantime, basic research on glucocorticoid effects and detailed reports on therapeutic efficacy and occurrence of adverse effects will be valuable in weighing benefits and risks in clinical practice.

Fertility in women with rheumatoid arthritis: influence of disease activity and medication

OBJECTIVES

Many female rheumatoid arthritis (RA) patients attempting to conceive have a time to pregnancy (TTP) of >12 months. During this period RA often cannot be treated optimally. We sought to identify clinical factors associated with prolonged TTP in female RA patients.

METHODS

In a nationwide prospective cohort study on pregnancy in RA patients (PARA study), women were included preconceptionally or during the first trimester. Cox regression analysis was used to study the association of disease characteristics and medication use with TTP.

RESULTS

TTP exceeded 12 months in 42% of 245 patients. Longer TTP was related to age, nulliparity, disease activity (DAS28), and preconception use of non-steroidal anti-inflammatory drugs (NSAIDs) and prednisone. These variables were independently associated with TTP, with HRs for occurrence of pregnancy of 0.96 (95% CI 0.92 to 1.00) per year of age, 0.52 (0.38 to 0.70) for nulliparity, 0.81 (0.71 to 0.93) per point increase in DAS28, 0.66 (0.46 to 0.94) for NSAIDs and 0.61 (0.45 to 0.83) for prednisone use. The impact of prednisone use was dose dependent, with significantly longer TTP when daily dose was >7.5 mg. Smoking, disease duration, rheumatoid factor, anti-citrullinated protein antibodies, past methotrexate use, and preconception sulfasalazine use did not prolong TTP.

CONCLUSIONS

TTP in RA is longer if patients are older or nulliparous, have higher disease activity, use NSAIDs or use prednisone >7.5 mg daily. Preconception treatment strategies should aim at maximum suppression of disease activity, taking account of possible negative effects of NSAIDs use and higher prednisone doses.

Safety of low- to medium-dose glucocorticoid treatment in rheumatoid arthritis: myths and reality over the years

Low- to medium-dose glucocorticoids have been shown to have not only anti-inflammatory but also disease-modifying properties in rheumatoid arthritis. The evidence for the benefit of its early use in combination with disease-modifying antirheumatic drugs underlines the need for a close evaluation of their risk-benefit ratio. Over time, numerous myths and fears about glucocorticoid toxicity in rheumatoid arthritis have arisen from observational studies, and many concerns have been unduly extrapolated from observations with higher-dose treatment. Furthermore, we cannot exclude the possibility of a powerful effect of bias by indication in these studies. Low- to medium-dose glucocorticoid regimens continued to be evaluated in randomized clinical trials, particularly in early disease, but these studies also have relevant methodological limitations in assessing safety, particularly due to small size and/or short duration. At present, the evidence on which to support clear recommendations about glucocorticoid toxicity remains remarkably weak. A large prospective pragmatic trial dedicated to the toxicity of low-dose glucocorticoids is dearly needed. Meanwhile, adherence to recommendations on standardized methodologies for registration and report of glucocorticoid adverse events is essential for improving our knowledge and competence in the best management of these important medications.