Perspectives of Glucocorticoid Use in Patients with Rheumatoid Arthritis

The Burden of Glucocorticoids: Patterns of Use, Adverse Health Conditions, and Health Care Use in Two Cohorts With Systemic Lupus Erythematosus

OBJECTIVE

Glucocorticoids (GCs) can be beneficial from both clinical and patient perspectives, but side effects are well documented. We examined patterns of GC use over 15 years (2006-2021) and occurrence of adverse health conditions (AHCs) and health care use by GC exposure in two longitudinal cohorts with systemic lupus erythematosus (SLE).

METHODS

Data from the Lupus Outcomes Study (LOS; 2003-2015) and FORWARD cohort (2015-2021) were used. AHCs examined were diabetes, osteoporosis, nontraumatic fractures, cataracts, and infections. Health care use measures examined were the number of rheumatology and other provider visits, hospitalizations, and specific diagnostic tests. Kaplan-Meier analyses examined time to occurrence of each AHC. Cox regression analyses estimated the risk of occurrence of AHCs, controlling for covariates by GC use and by GC dose (0, 1-5, 5-7.5, and ≥7.5 mg).

RESULTS

GC use was relatively consistent over time. At baseline, individuals who used GCs in the LOS were more likely to report osteoporosis (adjusted odds ratio [aOR] 1.7, 95% confidence interval [CI] 1.2-2.6) and cataracts (aOR 1.6, 95% CI 1.04-2.6); individuals who used GCs in the FORWARD cohort were more likely to report diabetes (aOR 5.1, 95% CI 2.2-12.0), osteoporosis (aOR 4.5, 95% CI 2.6-8.0), and fractures (aOR 6.5, 95% CI 3.8-11.1). Individuals who used high doses of GCs in the LOS had greater incidence of osteoporosis, fracture, and cataracts. In the FORWARD cohort, a significant difference in incidence was noted only for infections. In both cohorts, individuals who used GCs had more rheumatology and other physician visits, and greater risk of hospitalization.

CONCLUSION

Despite recommendations on steroid sparing, a large portion of people with SLE appear to remain on steroids. These analyses provide additional evidence of the potential health and health care burden of GC use, underscoring the need for other effective treatments for individuals with SLE.

Addressing Glucocorticoid-Related Problems with the Clinical Pharmacist Collaboration in Rheumatology Practice: A Prospective Follow-Up Study

INTRODUCTION

Glucocorticoids (GCs) play a crucial role in the treatment of many rheumatic diseases regarding their anti-inflammatory and immunosuppressive effects. Inappropriate use of GCs can exacerbate GC-related problems besides complex treatment regimens and miscellaneous well-established adverse events. Although several guidelines exist for managing these problems, there is lack of real-life studies evaluating the problems at the patient level. This study aims to identify GC-related problems among patients with rheumatic diseases and address how they have been solved.

METHODS

This prospective follow-up study was conducted between January 2021 and June 2022 at a university rheumatology outpatient clinic and included patients using GCs. A clinical pharmacist assessed patients for possible GC-related problems at baseline, 3 months, and 6 months. Identified problems, their causes, interventions to address these problems, and their outcomes were categorized using the Pharmaceutical Care Network Europe (PCNE v9.1) classification system. The resolution of the problems was evaluated at the patient's next follow-up visit.

RESULTS

A total of 156 patients were included, and 236 GC-related problems were identified in 66% of the patients. Adverse drug events (possible) accounted for the highest proportion of GC-related problems (94.1%), and the most common causes were lack of laboratory monitoring of GC-related adverse events (41.5%) and lack of drug treatment despite existing indications (39.8%). The median cumulative prednisolone dose was higher in patients with GC-related problems (3115 vs. 5455 mg, p = 0.007). The clinical pharmacist suggested 381 interventions: 47.7% (n = 182) at the 'prescriber level', 31.8% (n = 121) at the 'patient level', and 20.5% (n = 78) at the 'drug level'. Of those interventions, 98% were accepted, and 80.1% of the problems were solved.

CONCLUSIONS

This study showed that the prevalence of GC-related problems is high in patients with rheumatic diseases. Integrating clinical pharmacists into the multidisciplinary rheumatology team provides an advantage in effectively identifying and managing GC-related problems at an early stage.

Consensus of the definitions of the OMERACT glucocorticoid impact core domain set for people with rheumatic and musculoskeletal diseases

BACKGROUND

The Outcome Measures in Rheumatology (OMERACT) Glucocorticoid (GC) Impact Working Group has been working to develop a core domain set to measure the impact of GCs on patients living with rheumatic and musculoskeletal diseases. The mandatory domains previously identified for inclusion in all clinical trials measuring the GC effects include infection, bone fragility, mood disturbance, hypertension, diabetes, weight, fatigue, and mortality. Before progressing to instrument selection, the Working Group sought to establish precise definitions of all mandatory domains within the core domain set.

METHODS

OMERACT methodology was applied with the use of evidence and consensus-based decision making of all stakeholder groups (patient research partners, health care professionals, clinician researchers, industry members and methodologists) to develop detailed definitions for the broad domain, target domain and domain components, taking into consideration sources of variability that could affect measurement of the domain.  The working group synthesized prior qualitative studies, quantitative work, and results from Delphi rounds, to develop a rich definition of 'what' is to be measured.

RESULTS

Between 2021 and 2023, the OMERACT Working Group on GC Impact conducted virtual meetings to establish domain definitions. First, we mapped each domain onto an OMERACT Core Area. All domains were primarily represented within the Pathophysiological Manifestations Core Area, except from Fatigue which was primarily Life Impact and Weight which spanned both Core Areas. Sources of variability included cultural factors, age, gender, education level, socioeconomic status, personal experiences, emotional state, and language barriers. The domain definitions will form the foundation for instrument selection and the initial step of domain / concept match and content validity in the OMERACT pillar of 'truth' before moving on to feasibility and discrimination.

CONCLUSION

The OMERACT GC Impact Working Group has developed and agreed upon detailed domain definitions for core domains. Future steps of the working group are to select instruments and develop the core outcome measurement set for clinical trials measuring the impact of GC on patients with rheumatic and musculoskeletal diseases.

Glucocorticoid-Induced Osteoporosis: Increased Awareness as a Management Strategy for Prevention of this Complication in Patients with Systemic Autoimmune Rheumatic Disease

BACKGROUND

It has been estimated that about 1% of the US population is treated with long-term glucocorticoids. High doses of glucocorticoids particularly those used by rheumatologists and oth- ers for systemic autoimmune rheumatic disease result in bone loss, causing glucocorticoid-induced osteoporosis and an increase in the risk of fractures. The increased risk is related to both the daily dose and the cumulative dose of the glucocorticoids. Despite the availability of effective preventative and treatment options, glucocorticoid-induced osteoporosis is often not mitigated with the use of these preventive therapies. The risk of glucocorticoid-induced osteoporosis often also goes under- recognized, because it occurs in a different group of patients compared to age-related osteoporosis. As a result, glucocorticoid-induced osteoporosis is not always treated until after fractures may have occurred. Our objective is to determine if a structured health-care provider's educational interven- tion with intermittent educational updates would lead to improvement in the identification, evalu- ation, and prevention of glucocorticoid-induced osteoporosisin those patients at the highest risk of glucocorticoid-induced osteoporosis.

METHODS

In this single-center, prospective study, patients over 40 years of age, receiving a total cumu- lative dose of glucocorticoids of >5 g or a single dose of >30 mg of prednisone or its equivalent was enrolled. All providers attended an academic Journal Club, where the current American College of Rheumatology guidelines regarding glucocorticoid-induced osteoporosiswas reviewed. All providers received monthly reminders during academic meetings within the department.

RESULTS

There was a statistically significant improvement between pre- and post-educational data, with increasing use of glucocorticoid-induced osteoporosis preventive measures, which was sus- tained over the 12-month duration of the study.

CONCLUSION

This research shows the importance of provider education as a means of disseminating information and improving the quality of patient care.

The prevalence of osteoporosis in rheumatoid arthritis patient: a systematic review and meta-analysis

Osteoporosis (OP) is one of the most commonly known extra-articular complications of rheumatoid arthritis (RA). Since the prevalence of OP is diverse in different studies and there is no general consensus about it, in this systematic review, we aimed to investigate the global prevalence of OP among RA patients. In this review, three databases including Medline via PubMed, Scopus, and Web of Science (Clarivate analytics) were searched by various keywords. After screening of retrieved papers, the related data of included papers were extracted and analyzed. To assess the risk of methodological bias of included studies, quality assessment checklist for prevalence studies was used. Because of heterogeneity among studies, random-effect model was used to pooled the results of primary studies. In this review, the results of 57 studies were summarized and the total included sample size was 227,812 cases of RA with 64,290 cases of OP. The summary point prevalence of OP among RA was estimated as 27.6% (95%CI 23.9-31.3%). Despite significant advances in prevention, treatment and diagnostic methods in these patients, it still seems that the prevalence of OP in these patients is high and requires better and more timely interventions.

The Patient Experience of Drug Side Effects in Rheumatoid Arthritis: Intriguing Data From an Exploratory Online Survey

Understanding adverse events (AEs) of disease-modifying antirheumatic drugs (DMARDs) for treatment of rheumatoid arthritis (RA) is critical to both patients and clinicians. AEs-"side effects" from the patient perspective-contribute significantly to patients' disease experience by interfering with activities of daily living and quality of life (QOL).¹.

Tanshinone I Mitigates Steroid-Induced Osteonecrosis of the Femoral Head and Activates the Nrf2 Signaling Pathway in Rats

Steroid-induced osteonecrosis of the femoral head (SIONFH) is a frequent orthopedic disease caused by long-term or high-dose administration of corticosteroids. Tanshinone I (TsI), a flavonoid compound isolated from Salvia miltiorrhiza Bunge, has been reported to inhibit osteoclastic differentiation in vitro. This study aimed to investigate whether TsI can ameliorate SIONFH. Herein, SIONFH was induced by intraperitoneal injection of 20 μg/kg lipopolysaccharide every 24 h for 2 days, followed by an intramuscular injection of 40 mg/kg methylprednisolone every 24 h for 3 days. Four weeks after the final injection of methylprednisolone, the rats were intraperitoneally administrated with low-dose (5 mg/kg) and high-dose (10 mg/kg) TsI once daily for 4 weeks. Results showed that TsI significantly alleviated osteonecrotic lesions of the femoral heads as determined by micro-CT analysis. Furthermore, TsI increased alkaline phosphatase activity and expressions of osteoblastic markers including osteocalcin, type I collagen, osteopontin, and Runt-related transcription factor 2 and decreased tartrate-resistant acid phosphatase activity and expressions of osteoclastic markers including cathepsin K and acid phosphatase 5. TsI also reduced inflammatory response and oxidative stress and activated the nuclear factor erythroid 2-related factor 2 (Nrf2) signaling pathway in the femoral heads. Taken together, our findings show that TsI can relieve SIONFH, indicating that it may be a candidate for preventing SIONFH.

Quality of life of patients with rheumatic diseases during the COVID-19 pandemic: The biopsychosocial path

BACKGROUND

Previous models that assess quality-of-Life (QoL) in patients with rheumatic diseases have a strong biomedical focus. We evaluated the impact of COVID-19 related-health care interruption (HCI) on the physical, psychological, social relationships and environment QoL-dimensions, and explored factors associated with QoL when patients were reincorporated to the outpatient clinic, and after six-month follow-up.

PATIENTS AND METHODS

Study phase-1 consisted of a COVID-19 survey administered from June 24th-October 31st 2020, to outpatients with rheumatic diseases who had face-to-face consultation at outpatient clinic reopening. Study phase-2 consisted of 3 consecutive assessments of patient´s QoL (WHOQOL-BREF), disease activity/severity (RAPID-3), and psychological comorbidity/trauma (DASS-21 and IES-R) to patients from phase-1 randomly selected. Sociodemographic, disease and treatment-related information, and comorbidities were obtained. Multiple linear regression analysis identified factors associated with the score assigned to each WHOQOL-BREF dimension.

RESULTS

Patients included (670 for phase-1 and 276 for phase-2), had primarily SLE and RA (44.2% and 34.1%, respectively), and all the dimensions of their WHOQOL-BREF were affected. There were 145 patients (52.5%) who referred HCI, and they had significantly lower dimensions scores (but the environment dimension score). Psycho-emotional factors (primarily feeling confused, depression and anxiety), sociodemographic factors (age, COVID-19 negative economic impact, years of scholarship, HCI and having a job), and biomedical factors (RAPID-3 score and corticosteroid use) were associated with baseline QoL dimensions scores. Psycho-emotional factors showed the strongest magnitude on dimensions scores. Most consistent predictor of six-month follow-up QoL dimensions scores was each corresponding baseline dimension score, while social determinants (years of scholarship and having a job), emotional factors (feeling bored), and biomedical aspects (RAPID 3) had an additional impact.

CONCLUSIONS

HCI impacted the majority of patient´s QoL dimensions. Psycho-emotional, sociodemographic and biomedical factors were consistently associated with QoL dimensions scores, and these consistently predicted the QoL trajectory.

Perspectives on glucocorticoid usage in patients with adult inflammatory myopathy

This study aims to describe the patient perspective on glucocorticoid (GC) treatment and adverse effects (AEs) in idiopathic inflammatory myopathy (IIM). An online survey was distributed to patients with adult-onset IIM using the Myositis UK page on Healthunlocked.com, an online social network for health. Respondents were asked to rate the severity of AEs they attributed to GCs on a Likert scale (0-5), and to report concerns and overall experience of GC treatment. The survey was completed by 122 respondents. The median reported current daily dose of prednisolone was 15 mg (interquartile range [IQR] 8, 25) and median treatment duration 5.3 years (IQR 3.4, 8.0) at the time of survey completion. Only 54% of respondents "agreed" or "strongly agreed" that the information provided to them about GC treatment was adequate. AEs rated most severe by respondents were weight gain, moon face, sleep disturbances and increased hunger. The duration of GC treatment weakly correlated with the mean number of reported AEs (p = 0.004) and mean severity of AEs (p = 0.017). There was an inverse relationship between age and acne, stretch marks, hair loss, facial hair, nausea and heartburn (p < 0.05). In this first study of patient-reported experiences of GCs specifically in IIM, we describe the burden of treatment and highlight the unmet need for safe and well-tolerated treatments. We report that patients with IIM often remain on long-term GC treatment at moderate doses, and that AEs are common. The reported data will be useful in planning discussions with patients regarding adherence to their treatment options. Key Points • Glucocorticoids (GC) are the first-line treatment in patients with idiopathic inflammatory myopathies (IIM), and are associated with a wide range of adverse effects • The adverse effects related to GC are very common, and those reported most severe by patients included weight gain, moon face, increased hunger or sleep disturbance, which may differ from the primary concerns of their treating clinician • Understanding the patient perspective and concerns about treatment is necessary to maintain a good physician-patient relationship and may help with treatment adherence.

Improving benefit-harm assessment of glucocorticoid therapy incorporating the patient perspective: The OMERACT glucocorticoid core domain set

OBJECTIVE

Our primary objective was to develop an Outcome Measures in Rheumatology (OMERACT) core domain set to capture the impact of glucocorticoids (GC), both positive and negative, on patients with Rheumatic conditions.

METHODS

The OMERACT Filter 2.1 was used to guide core domain selection. Systematic literature reviews, qualitative studies and quantitative surveys were conducted by the OMERACT GC Impact working group to identify candidate domains for a core domain set. A summary of prior work and Delphi exercise were presented at the OMERACT 2020 virtual GC workshop. A proposed GC Impact core domain set derived from this work was presented for discussion in facilitated breakout groups. Participants voted on the proposed GC Impact core domain set.

RESULTS

113 people, including 23 patient research partners, participated in two virtual workshops conducted at different times on the same day. The proposed mandatory domains to be evaluated in clinical trials involving GCs were: infection, bone fragility, hypertension, diabetes, weight, fatigue, mood disturbance and death. In addition, collection of disease specific outcomes was included in the core domain set as "mandatory in specific circumstances". The proposed core domain set was endorsed by 100% (23/23) of the patient research partners and 92% (83/90) of the remaining participants, including clinicians, researchers and industry stakeholders.

CONCLUSION

A GC Impact core domain set was endorsed at the OMERACT 2020 virtual workshop. The OMERACT GC Impact working group will now progress to identify, develop and validate measurement tools to best address these domains in clinical trials.