A Bridge Too Far? Real-World Practice Patterns of Early Glucocorticoid Use in the Canadian Early Arthritis Cohort

Initiation of glucocorticoids before entering rheumatology care associates with long-term glucocorticoid use in older adults with early rheumatoid arthritis: A joint analysis of Medicare and the Rheumatology Informatics System for Effectiveness (RISE) data

OBJECTIVE

To assess relationships between the timing of glucocorticoid (GC) initiation, entrance into rheumatology care, and the duration of GC use in older adults with early rheumatoid arthritis (eRA) in the U.S.

METHODS

Data from the Rheumatology Informatics System for Effectiveness (RISE) registry and Medicare (2016-2018) were linked. Patients with ≥2 RA ICD codes in RISE were included; the first being the index date which signaled entrance into rheumatology care. GC initiation (between 3 months before to 6 months after the index date) and continuous GC use up to 12 months after the index date were captured using Medicare claims. Cox proportional hazards models with adjustment for confounders assessed differences in the duration of GC use for patients initiating GCs before versus after the index date. Average daily GC doses were estimated.

RESULTS

1,733 patients (67 % female; mean age 76 ± 6 years) were included. 41 % initiated GCs, on average 16 ± 58 days before entering rheumatologic care. The mean duration of GC use was 157 days (95 %-CI 143 to 170). GC initiation before rheumatologic care was associated with longer GC use, even after adjustment for confounders (hazard ratio 0.61; 95 %-CI [0.51 to 0.74]). For patients using GCs for ≥3 months, average daily GC doses were <5 mg/d prednisone equivalent.

CONCLUSION

GCs are regularly used in eRA and most often initiated before patients enter rheumatology care. Long-term, low-dose GC use is common and associated with initiation before rheumatology care. Earlier referral to rheumatology might reduce GC exposure among U.S. patients with eRA.

Osteoporosis and fracture risk are multifactorial in patients with inflammatory rheumatic diseases

Patients with inflammatory rheumatic and musculoskeletal diseases (iRMDs) such as rheumatoid arthritis, connective tissue diseases, vasculitides and spondyloarthropathies are at a higher risk of osteoporosis and fractures than are individuals without iRMDs. Research and management recommendations for osteoporosis in iRMDs often focus on glucocorticoids as the most relevant risk factor, but they largely ignore disease-related and general risk factors. However, the aetiopathogenesis of osteoporosis in iRMDs has many facets, including the negative effects on bone health of local and systemic inflammation owing to disease activity, other iRMD-specific risk factors such as disability or malnutrition (for example, malabsorption in systemic sclerosis), and general risk factors such as older age and hormonal loss resulting from menopause. Moreover, factors that can reduce fracture risk, such as physical activity, healthy nutrition, vitamin D supplementation and adequate treatment of inflammation, are variably present in patients with iRMDs. Evidence relating to general and iRMD-specific protective and risk factors for osteoporosis indicate that the established and very often used term 'glucocorticoid-induced osteoporosis' oversimplifies the complex inter-relationships encountered in patients with iRMDs. Osteoporosis in these patients should instead be described as 'multifactorial'. Consequently, a multimodal approach to the management of osteoporosis is required. This approach should include optimal control of disease activity, minimization of glucocorticoids, anti-osteoporotic drug treatment, advice on physical activity and nutrition, and prevention of falls, as well as the management of other risk and protective factors, thereby improving the bone health of these patients.

Continuing versus tapering low-dose glucocorticoids in patients with rheumatoid arthritis and systemic lupus erythematosus in states of low disease activity or remission: A systematic review and meta-analysis of randomised trials

OBJECTIVES

To study the benefit and harm associated with continuing versus tapering low-dose glucocorticoids (GCs) in patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) who have achieved low disease activity/remission.

METHODS

A protocolised (PROSPEROCRD42022325175) systematic review and meta-analysis of randomised trials was performed. Trials compared, in patients with low disease activity/remission and GCs at baseline, continued low-dose GCs (≤7.5 mg/d prednisone equivalent) with a taper. Co-primary outcomes were time to flare and adverse events (AEs), accompanied by secondary benefit and harm outcomes. We performed meta-analyses and evaluated risk of bias and quality of evidence (QoE). Subgroup analyses were conducted for patients with RA.

RESULTS

Four trials (three: RA; one: SLE; study duration 24-104 weeks) with 472 participants were included. Tapering GCs resulted in a shorter time to flare (hazard ratio 3.41 [95 %-CI 1.96-5.93]; p<0.01; very low QoE). The risks of AEs, serious AEs, and withdrawal due to AEs were similar in both groups (very low to low QoE). There were more withdrawals due to lack of efficacy with tapered GCs (risk ratio 3.02 [1.56-5.87]; low QoE). In RA, the disease activity score-28 was lower with continued GCs (mean difference 0.49 [0.07-0.91]; low QoE). One of 238 patients in the tapering groups experienced adrenal insufficiency. Subgroup analyses yielded consistent results.

CONCLUSION

In RA and SLE with low disease activity, continuing low-dose GCs may provide better sustained disease control, but QoE is insufficient. Adrenal insufficiency is very rare when tapering low-dose GCs. Longer-term safety concerns for GCs remain.

The Effect of Low-Dose Glucocorticoids Over Two Years on Weight and Blood Pressure in Rheumatoid Arthritis: Individual Patient Data From Five Randomized Trials

BACKGROUND

Weight gain and hypertension are well known adverse effects of treatment with high-dose glucocorticoids.

OBJECTIVE

To evaluate the effects of 2 years of low-dose glucocorticoid treatment in rheumatoid arthritis (RA).

DESIGN

Pooled analysis of 5 randomized controlled trials with 2-year interventions allowing concomitant treatment with disease-modifying antirheumatic drugs.

SETTING

12 countries in Europe.

PATIENTS

Early and established RA.

INTERVENTION

Glucocorticoids at 7.5 mg or less prednisone equivalent per day.

MEASUREMENTS

Coprimary end points were differences in change from baseline in body weight and mean arterial pressure after 2 years in intention-to-treat analyses. Difference in the change of number of antihypertensive drugs after 2 years was a secondary end point. Subgroup and sensitivity analyses were done to assess the robustness of primary findings.

RESULTS

A total of 1112 participants were included (mean age, 61.4 years [SD, 14.5]; 68% women). Both groups gained weight in 2 years, but glucocorticoids led, on average, to 1.1 kg (95% CI, 0.4 to 1.8 kg; P < 0.001) more weight gain than the control treatment. Mean arterial pressure increased by about 2 mm Hg in both groups, with a between-group difference of -0.4 mm Hg (CI, -3.0 to 2.2 mm Hg; P = 0.187). These results were consistent in sensitivity and subgroup analyses. Most patients did not change the number of antihypertensive drugs, and there was no evidence of differences between groups.

LIMITATION

Body composition was not assessed, and generalizability to non-European regions may be limited.

CONCLUSION

This study provides robust evidence that low-dose glucocorticoids, received over 2 years for the treatment of RA, increase weight by about 1 kg but do not increase blood pressure.

PRIMARY FUNDING SOURCE

None.

Sex and age do not modify the association between glucocorticoids and bone mineral density in patients with rheumatoid arthritis: a cross-sectional study

BACKGROUND

It is unclear whether sex or age modify the association of glucocorticoid (GC) use with reduced bone mineral density (BMD) in patients with rheumatoid arthritis (RA).

METHODS

We studied cross-sectional data of RA patients with current or previous GC treatment in a single center cohort study (Rh-GIOP cohort). Our primary outcome was the minimum T-score (measured by DXA) of either lumbar spine, total femur, or femoral neck. Current GC dose was the main exposure; cumulative GC dose and cumulative duration of GC use were also assessed. Following a predefined statistical analysis plan, linear regression analyses with adjustment for confounders assessed whether the association of GC use with BMD was modified by sex (men versus women) or age (≥ 65 versus < 65 years).

RESULTS

Four hundred eighty-three patients with RA (mean age 64 ± 12 years, 80% women) were included. 33% were not currently taking GCs, 32% were treated with a dose of 5 mg/d prednisone equivalent and 11% with more than 7.5 mg/d. 23% of patients had osteoporosis by DXA (minimum T-score ≤ -2.5). The slope, i.e., the association between changes in minimum T-scores with 1 mg/d change in current GC dose, was similar in men and women (-0.07 and -0.04, respectively; difference -0.03 [-0.11 to 0.04]; p for interaction = 0.41). Slopes were also similar for elderly and non-elderly patients (-0.03 and -0.04, respectively; difference -0.01 [-0.06 to 0.05]; p for interaction = 0.77). Using cumulative dose and duration of use as exposures did not lead to substantial changes of these results.

CONCLUSIONS

In our sample, the association of GC use with reduced BMD in RA was not modified by sex or age.

Glucocorticoids in rheumatoid arthritis: Balancing benefits and harm by leveraging the therapeutic window of opportunity

Glucocorticoids have been available since the early 1950s and have since become an integral part of the management of rheumatoid arthritis (RA). Due to their rapid effect, glucocorticoids have an appealing profile for treating flares or as "bridging" agents in early RA. The efficacy of glucocorticoids to treat RA has been well established, both to control disease activity and to delay the progression of joint damage. However, despite their benefits, glucocorticoids have equally well-known adverse effects. It is generally accepted that long-term use of glucocorticoids, particularly at higher doses, is not advisable, and recent guidelines for the management of RA therefore either recommend against the use of glucocorticoids or suggest using them only as bridging therapy. Perceptions on the harmful effects of glucocorticoids remain, although mainly based on observational studies. Prolonged glucocorticoid therapy at low doses is still highly prevalent in clinical practice, but recent data suggest a rather favourable risk-benefit balance for this strategy, even in senior patients. Balancing the benefits and risks of treating RA with glucocorticoids thus remains a somewhat controversial topic. This narrative review outlines the historical and current position of glucocorticoids in the management of RA, while summarising recent evidence on their beneficial and detrimental effects. Furthermore, practical strategies for the current use and tapering of glucocorticoids in RA are formulated.