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Palmowski A, Roberts ET, Li J, Kersey E, Stovall R, Buttgereit F, Yazdany J, Schmajuk G. 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. Semin Arthritis Rheum 2024; 68:152535. [PMID: 39182392 DOI: 10.1016/j.semarthrit.2024.152535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 07/08/2024] [Accepted: 07/23/2024] [Indexed: 08/27/2024]
Abstract
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.
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Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Section for Biostatistics and Evidence-Based Research, the Parker Institute, University of Copenhagen, Copenhagen, Denmark; Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA.
| | - Eric T Roberts
- Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | - Jing Li
- Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | - Emma Kersey
- Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | - Rachael Stovall
- Division of Rheumatology, University of Washington, Seattle, WA, USA
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jinoos Yazdany
- Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
| | - Gabriela Schmajuk
- Division of Rheumatology, University of California San Francisco, San Francisco, CA, USA
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2
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Cutolo M, Shoenfeld Y, Bogdanos DP, Gotelli E, Salvato M, Gunkl-Tóth L, Nagy G. To treat or not to treat rheumatoid arthritis with glucocorticoids? A reheated debate. Autoimmun Rev 2024; 23:103437. [PMID: 37652398 DOI: 10.1016/j.autrev.2023.103437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023]
Abstract
The therapeutic landscape of rheumatoid arthritis (RA) has rapidly evolved in the last few decades. At the same time, recommendations for the management of the disease suggest to minimize glucocorticoids (GCs) use in RA patients. Major concerns are the risk of long-term adverse events and the difficulties in discontinuing GCs once initiated. However, real-world data show that up to 50% of RA patients continue to take GCs during the disease course. Adverse events of GCs usually occur after a long-term use, which can limit the generalizability of randomized controlled trials (RCTs) proving no or minimal harm. Observational studies show conflicting results regarding the safety of GSs and are subjected to a high risk of bias, including indication bias. Thus, whether or not GCs should be used in the management of RA is still a matter of debate. The main reasons to support GCs use are the ability to rapidly suppress joint inflammation while waiting for the full effect of conventional synthetic disease-modifying antirheumatic drugs (csDMARD) and the acknowledged efficacy on radiographic progression in early RA. The main reasons to avoid GCs use in RA are that their potential risks may outweigh their benefits and there is no agreement on the minimal daily dosage of GC which can be considered safe.
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Affiliation(s)
- Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Department of Internal Medicine (DiMI), University of Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Yehuda Shoenfeld
- Reichman University, Herzelia, Israel; Zabludowicz Center for Autoimmunity, Sheba Medical Center, Israel.
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, University of Thessaly Medical School, Larissa, Greece
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Department of Internal Medicine (DiMI), University of Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Mariangela Salvato
- Department of Medicine DIMED, Division of Rheumatology, University of Padua, Padua, Italy
| | - Lilla Gunkl-Tóth
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary; Department of Pharmacology and Pharmacotherapy, University of Pécs, Pécs, Hungary; ELKH Chronic Pain Research Group, Pécs, Hungary
| | - György Nagy
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary; Heart and Vascular Center, Semmelweis University, Budapest, Hungary; Department of Genetics, Cell- and Immunobiology, Semmelweis University, Budapest, Hungary; Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
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3
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Palmowski A, Nielsen SM, Boyadzhieva Z, Hartman L, Oldenkott J, Svensson B, Hafström I, Wassenberg S, Choy E, Kirwan J, Christensen R, Boers M, Buttgereit F. The Effect of Low-Dose Glucocorticoids Over Two Years on Weight and Blood Pressure in Rheumatoid Arthritis: Individual Patient Data From Five Randomized Trials. Ann Intern Med 2023; 176:1181-1189. [PMID: 37579312 DOI: 10.7326/m23-0192] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
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.
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Affiliation(s)
- Andriko Palmowski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Berlin, Germany, Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, Denmark (A.P.)
| | - Sabrina M Nielsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Frederiksberg, and Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark (S.M.N.)
| | - Zhivana Boyadzhieva
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Berlin, Germany (Z.B., J.O., F.B.)
| | - Linda Hartman
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands (L.H.)
| | - Judith Oldenkott
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Berlin, Germany (Z.B., J.O., F.B.)
| | - Björn Svensson
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Rheumatology, Lund, Sweden (B.S.)
| | - Ingiäld Hafström
- Division of Gastroenterology and Rheumatology, Department of Medicine Huddinge, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden (I.H.)
| | | | - Ernest Choy
- CREATE Centre, Section of Rheumatology, Cardiff University, Cardiff, United Kingdom (E.C.)
| | - John Kirwan
- University of Bristol, Bristol, United Kingdom (J.K.)
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Research Unit of Rheumatology, Frederiksberg, and Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark (R.C.)
| | - Maarten Boers
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (M.B.)
| | - Frank Buttgereit
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Rheumatology and Clinical Immunology, Berlin, Germany (Z.B., J.O., F.B.)
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Maleitzke T, Wiebe E, Huscher D, Spies CM, Tu J, Gaber T, Zheng Y, Buttgereit F, Seibel MJ, Zhou H. Transgenic disruption of endogenous glucocorticoid signaling in osteoblasts does not alter long-term K/BxN serum transfer-induced arthritis. Arthritis Res Ther 2023; 25:140. [PMID: 37542341 PMCID: PMC10401869 DOI: 10.1186/s13075-023-03112-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/11/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Disruption of glucocorticoid (GC) signaling in osteoblasts results in a marked attenuation of acute antibody-induced arthritis. The role of endogenous GCs in chronic inflammatory arthritis is however not fully understood. Here, we investigated the impact of endogenous GC signaling in osteoblasts on inflammation and bone integrity under chronic inflammatory arthritis by inactivating osteoblastic GC signaling in a long-term K/BxN serum transfer-induced induced arthritis (STIA) model. METHODS Intracellular GC signaling in osteoblasts was disrupted by transgenic (tg) overexpression of 11beta-hydroxysteroid dehydrogenase type 2 (11ß-HSD2). Inflammatory arthritis was induced in 5-week-old male tg mice and their wild type (WT) littermates by intraperitoneal (i.p.) injection of K/BxN serum while controls (CTRLs) received phosphate-buffered saline (PBS). In a first cohort, K/BxN STIA was allowed to abate until the endpoint of 42 days (STIA). To mimic rheumatic flares, a second cohort was additionally injected on days 14 and 28 with K/BxN serum (STIA boost). Arthritis severity was assessed daily by clinical scoring and ankle size measurements. Ankle joints were assessed histopathologically. Systemic effects of inflammation on long bone metabolism were analyzed in proximal tibiae by micro-computed tomography (μCT) and histomorphometry. RESULTS Acute arthritis developed in both tg and WT mice (STIA and STIA boost) and peaked around day 8. While WT STIA and tg STIA mice showed a steady decline of inflammation until day 42, WT STIA boost and tg STIA boost mice exhibited an arthritic phenotype over a period of 42 days. Clinical arthritis severity did not differ significantly between WT and tg mice, neither in the STIA nor in the STIA boost cohorts. Correspondingly, histological indices of inflammation, cartilage damage, and bone erosion showed no significant difference between WT and tg mice on day 42. Histomorphometry revealed an increased bone turnover in tg CTRL and tg STIA boost compared to WT CTRL and WT STIA boost animals, respectively. CONCLUSIONS In contrast to the previously reported modulating effects of endogenous GC signaling in osteoblasts during acute K/BxN STIA, this effect seems to perish during the chronic inflammatory and resolution phase. These findings indicate that endogenous GC signaling in osteoblasts may mainly be relevant during acute and subacute inflammatory processes.
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Affiliation(s)
- Tazio Maleitzke
- Bone Research Program, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
- Julius Wolff Institute, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- BIH Charité Clinician Scientist Program, BIH Biomedical Innovation Academy, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Edgar Wiebe
- Bone Research Program, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia.
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany.
| | - Dörte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Cornelia M Spies
- Bone Research Program, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Jinwen Tu
- Bone Research Program, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Timo Gaber
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Yu Zheng
- Bone Research Program, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Berlin, Germany
| | - Markus J Seibel
- Bone Research Program, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
- Department of Endocrinology and Metabolism, Concord Repatriation Hospital, University of Sydney, Sydney, NSW, Australia
| | - Hong Zhou
- Bone Research Program, ANZAC Research Institute, University of Sydney, Sydney, NSW, Australia
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5
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Hanberg JS, Miloslavsky EM. Steroid sparing in vasculitis: Myth or reality? Best Pract Res Clin Rheumatol 2023; 37:101843. [PMID: 37355346 DOI: 10.1016/j.berh.2023.101843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/13/2023] [Accepted: 05/18/2023] [Indexed: 06/26/2023]
Abstract
Glucocorticoids are the cornerstone of therapy for all forms of vasculitis. However, glucocorticoid treatment carries with it the risk of glucocorticoid toxicity. Recent research efforts in vasculitis have emphasized investigation into strategies that reduce glucocorticoid exposure. These strategies include the adoption of rapid-acting steroid-sparing agents, reduced-dose glucocorticoid induction regimens, the early introduction of steroid-sparing agents for maintenance therapy, and the extension of maintenance therapy to minimize glucocorticoid exposure associated with disease relapse. These are critical advances to move us toward the goal of glucocorticoid-free treatment of vasculitis. The evidence supporting each of these strategies and directions for future research are explored.
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Affiliation(s)
| | - Eli M Miloslavsky
- Rheumatology Unit, Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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de Boysson H, Barakat C, Dumont A, Boutemy J, Martin Silva N, Maigné G, Nguyen A, Lavergne A, Castan P, Gallou S, Sultan A, Deshayes S, Aouba A. Tolerance of glucocorticoids in giant cell arteritis: a study of patient-reported adverse events. Rheumatology (Oxford) 2022; 61:3567-3575. [PMID: 34919673 DOI: 10.1093/rheumatology/keab921] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/05/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess patients' self-reported glucocorticoid (GC)-related adverse events (AEs) in a GCA population. METHODS A questionnaire was sent to the 100 patients most recently diagnosed with GCA in a tertiary centre. This questionnaire included open- and close-ended questions on the disease and GC effects. Eight primary AE areas were analysed: cardiovascular, metabolic, muscle, cognitive and psychologic, bone, cutaneous and hairiness, infective and visual complications. Including derivative subitems from preceding areas, a total of 18 GC-related AEs were analysed separately and according to GC duration. RESULTS Ninety patients were analysed and 89 (99%) reported at least one GC-related AE [median 6 (range 1-11)]. Cognitive and psychological changes, primarily insomnia (72%), affected 90% of patients. Cutaneous changes and muscle loss affected 70% of patients, with frequent impairment of physical autonomy (P = 0.007) associated with this event. Metabolic issues, especially weight gain (40%) and diabetes mellitus (20%), affected 49% of patients. Conversely, vision troubles and bone fractures were mentioned by 42% and 9% of patients, respectively, and more frequently in patients who received GCs for >18 months (P = 0.01 and P = 0.007, respectively). Cardiovascular changes and infections affected 30% and 26% of patients, respectively. CONCLUSION This real-life study of GC tolerance assessed using a self-evaluation provides pragmatic and updated data reminding us that GC tolerance remains more noteworthy than ever. This study suggests carefully monitoring GC-related AEs during follow-up and encourages GC-sparing strategies in some patients.
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Affiliation(s)
- Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
| | - Clivia Barakat
- Department of Internal Medicine, Caen University Hospital
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
| | | | | | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital
| | - Alexandre Nguyen
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
| | | | - Paul Castan
- Department of Internal Medicine, Caen University Hospital
| | - Sophie Gallou
- Department of Internal Medicine, Caen University Hospital
| | - Audrey Sultan
- Department of Internal Medicine, Caen University Hospital
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital
- Caen University-Normandie, Caen, France
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7
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Wiebe E, Huscher D, Schaumburg D, Palmowski A, Hermann S, Buttgereit T, Biesen R, Burmester GR, Palmowski Y, Boers M, Stone JH, Dejaco C, Buttgereit F. Optimising both disease control and glucocorticoid dosing is essential for bone protection in patients with rheumatic disease. Ann Rheum Dis 2022; 81:1313-1322. [PMID: 35680387 PMCID: PMC9380479 DOI: 10.1136/annrheumdis-2022-222339] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/08/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Inflammatory rheumatic and musculoskeletal diseases (iRMDs) are associated with increased systemic bone loss that is mediated by chronic inflammation, treatment with glucocorticoids (GCs) and other factors. Our objective was to analyse the impact of variables that influence osteoporosis (OP) in patients with iRMD treated with GC. METHODS Rh-GIOP (acronyme) is a prospective observational cohort study investigating bone health in consecutive patients with iRMD and current or prior GC treatment. We present an analysis of the patients' baseline data here. Bone mineral density (BMD) measured by dual X-ray absorptiometry was the primary outcome. Multivariable linear regression models were performed to identify variables associated with BMD. RESULTS Data from 1066 patients with iRMD were analysed. GC doses of <5 mg prednisone equivalent per day, cumulative dose and duration of GC therapy were not associated with negative effects on BMD. Dosages of ≥5 mg/day lost their negative association with BMD after adjustment for confounders. When subanalysing patients with exactly 5 mg/day, no negative effect was seen. For patients with rheumatoid arthritis (RA), GC doses of >7.5 mg/day showed a negative association with BMD overall, but this effect seemed to be specific only to patients with moderate or high disease activity (Disease Activity Score 28-C reactive protein >3.2). CONCLUSIONS GCs of ≤5 mg/day did not seem to be associated with a reduction of BMD in patients with iRMD and current or prior exposure to GC. This is most likely due to the dampening of inflammation by GC, which exerts a mitigating effect on the risk of OP. In RA, current GC doses of >7.5 mg/day were negatively associated with BMD, but only in patients with moderate to high disease activity. TRIAL REGISTRATION NUMBER NCT02719314.
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Affiliation(s)
- Edgar Wiebe
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dörte Huscher
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Désireé Schaumburg
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sandra Hermann
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Buttgereit
- Department of Dermatology, Venerology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Berlin, Germany
- Institute of Allergology, Charité, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Berlin, Germany
| | - Robert Biesen
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerd-Rüdiger Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Yannick Palmowski
- Center for Musculoskeletal Surgery, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Maarten Boers
- Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, Netherlands
| | - John H Stone
- Vasculitis and Glomerulonephritis Center, Rheumatology, Immunology and Allergy Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christian Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria
- Rheumatology, Brunico Hospital (SABES-ASDAA), Brunico, Italy
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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8
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Luís M, Boers M, Saag K, Buttgereit F, da Silva JAP. The safety of glucocorticoids in the treatment of inflammatory rheumatic disease: new evidence. Curr Opin Rheumatol 2022; 34:179-186. [PMID: 35238807 DOI: 10.1097/bor.0000000000000870] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Glucocorticoids justifiably remain a cornerstone in the treatment of many inflammatory rheumatic diseases but many are opposed to their use because of the side effects, most of them known to be dose-dependent. Most concerns regarding glucocorticoids stem from observational studies which are affected by several forms of bias, mainly confounding by indication, that may result in overestimation of harm. Solid evidence regarding the safety of low-dose glucocorticoids remains remarkably scarce. RECENT FINDINGS Several observational studies showed heterogeneous results and two 6-month trials showed no increase of harm. The GLORIA trial of 5 mg/day prednisolone vs. placebo in patients aged 65+ is the first randomized control trial with glucocorticoids safety as coprimary outcome. The benefits of glucocorticoids in terms of symptoms and structural damage were confirmed, but the proportion of patients with at least one adverse event of special interest (serious or glucocorticoids-related) was increased by 24%, mostly due to nonsevere infections. SUMMARY Based on current evidence the benefit-risk balance of low-dose glucocorticoids in rheumatoid arthritis, and probably in other rheumatic diseases is generally favourable. Physicians should be aware of the risks and mitigate them, but avoid the negative effects of unfounded fear.
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Affiliation(s)
- Mariana Luís
- Rheumatology Department, Centra Hospitalar e Universitário de Coimbra
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Maarten Boers
- Department of Epidemiology & Biostatistics, VU University Medical Center, Amsterdam
- Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ken Saag
- Division of Clinical Immunology and Rheumatology, Center for Education and Research on Therapeutics University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin, Germany
| | - José A P da Silva
- Rheumatology Department, Centra Hospitalar e Universitário de Coimbra
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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9
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Löhning M, Shen P, Dzamukova M, Durán-Hernández N, Roodselaar J, Hauser AE, Fiedler A, Niesner RA, Gaber T, Buttgereit F. [The DRFZ-a pioneer in research on the interaction between immune and stromal cells during de- and regeneration of the musculoskeletal system]. Z Rheumatol 2022; 81:652-659. [PMID: 35412048 DOI: 10.1007/s00393-022-01188-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 11/24/2022]
Abstract
Rheumatoid arthritis and osteoarthritis are two related chronic diseases of the musculoskeletal system which are particularly pronounced in the region of joints and bones. Their pathogeneses are associated with chronic inflammation, which can disrupt homeostasis in bones and articular cartilage. Degradation products deriving from articular cartilage can contribute to the exacerbation of inflammation in the joint region. Mechanical stimuli and blood vessels also play a central role in both the regulation of bone growth as well as in the regeneration of bone tissue. Not only chronic inflammatory processes but also hormonal changes after menopause or undesired effects of glucocorticoid therapy have an influence on the balance between bone resorption and deposition, by promoting the former and reducing the latter. This results in decreased bone quality and, in some cases, considerable loss of bone or osteoporosis. An in-depth understanding of these processes at the molecular, cellular, and tissue level, as well as of the changes present in chronic inflammatory diseases, has been the focus of research at the German Rheumatism Research Center (Deutsches Rheuma-Forschungszentrum, DRFZ) since its foundation. Based on an improved understanding of these mechanisms, the DRFZ aims to develop improved prevention and treatment strategies with effects even in early disease stages.
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Affiliation(s)
- Max Löhning
- Deutsches Rheuma-Forschungszentrum Berlin (DRFZ), Leibniz-Institut, Charitéplatz 1, 10117, Berlin, Deutschland. .,Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland.
| | - Ping Shen
- Deutsches Rheuma-Forschungszentrum Berlin (DRFZ), Leibniz-Institut, Charitéplatz 1, 10117, Berlin, Deutschland.,Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Maria Dzamukova
- Deutsches Rheuma-Forschungszentrum Berlin (DRFZ), Leibniz-Institut, Charitéplatz 1, 10117, Berlin, Deutschland.,Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Nayar Durán-Hernández
- Deutsches Rheuma-Forschungszentrum Berlin (DRFZ), Leibniz-Institut, Charitéplatz 1, 10117, Berlin, Deutschland.,Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Jay Roodselaar
- Deutsches Rheuma-Forschungszentrum Berlin (DRFZ), Leibniz-Institut, Charitéplatz 1, 10117, Berlin, Deutschland.,Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Anja E Hauser
- Deutsches Rheuma-Forschungszentrum Berlin (DRFZ), Leibniz-Institut, Charitéplatz 1, 10117, Berlin, Deutschland.,Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Alexander Fiedler
- Deutsches Rheuma-Forschungszentrum Berlin (DRFZ), Leibniz-Institut, Charitéplatz 1, 10117, Berlin, Deutschland.,Institut für Veterinär-Physiologie, Freie Universität Berlin, Berlin, Deutschland
| | - Raluca A Niesner
- Deutsches Rheuma-Forschungszentrum Berlin (DRFZ), Leibniz-Institut, Charitéplatz 1, 10117, Berlin, Deutschland.,Institut für Veterinär-Physiologie, Freie Universität Berlin, Berlin, Deutschland
| | - Timo Gaber
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Frank Buttgereit
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
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10
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How to taper glucocorticoids in inflammatory rheumatic diseases? A narrative review of novel evidence in rheumatoid arthritis, systemic lupus erythematosus, and giant cell arteritis. Joint Bone Spine 2021; 89:105285. [PMID: 34601110 DOI: 10.1016/j.jbspin.2021.105285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/22/2021] [Indexed: 01/24/2023]
Abstract
Glucocorticoids (GCs) remain regularly used drugs in patients with chronic inflammatory rheumatic diseases. As long-term intake at high dosages is associated with harm, it is generally advised that GCs be tapered and stopped. However, most recommendations concerning tapering have been eminence- or consensus-based. In this narrative review, we present novel data from recent studies (SEMIRA, CORTICOLUP, and GiACTA) shedding light from different angles on the effects of tapering GCs in patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and giant cell arteritis (GCA). In RA and SLE, our main findings comprise that (a) the majority of RA and SLE patients can successfully taper their GC, but that (b) tapering increases the risk of flare. In GCA, tocilizumab was shown to be a potent GC-sparing agent. Finally, we also present exemplary tapering schemes for RA, SLE, and GCA, although different tapering regimens have not yet been sufficiently compared in randomized trials.
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Cutolo M, Paolino S, Gotelli E. Glucocorticoids in rheumatoid arthritis still on first line: the reasons. Expert Rev Clin Immunol 2021; 17:417-420. [PMID: 33706640 DOI: 10.1080/1744666x.2021.1903319] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, IRCCS San Martino Polyclinic, Genova, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, IRCCS San Martino Polyclinic, Genova, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties, University of Genova, IRCCS San Martino Polyclinic, Genova, Italy
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12
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Hirata S, Kohno H, Watanabe H, Tokunaga T, Yoshida Y, Sugimoto T, Mokuda S, Oda K, Nojima T, Sugiyama E. Tapering and discontinuation of oral glucocorticoids without deterioration of disease status in patients with rheumatoid arthritis under a stable treatment. Mod Rheumatol 2021; 31:803-808. [PMID: 33325280 DOI: 10.1080/14397595.2020.1864914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To retrospectively evaluate whether oral glucocorticoid (GC) administration can be tapered or discontinued over a 2-year observation period in patients with rheumatoid arthritis (RA) undergoing a stable oral GC treatment, without deterioration in the disease status. METHODS Methotrexate (MTX) and prednisolone (PSL) dosages were increased and decreased, respectively, to the maximum extent possible. Concomitant biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) were used as required. Changes in PSL and MTX use and disease status were evaluated at baseline (BL), year-1, and year-2. RESULTS Thirty-six patients were enrolled (median age, 65.4 years; disease duration, 7.1 years). The proportion of patients using PSL decreased over 2 years (100-13.9%, p < .0001). While no change was observed in the proportion of patients using MTX, the average administered dose increased at year-1 (p = .06). Moreover, b/tsDMARDs were administered in nine patients (two in year-1, seven in year-2). The Clinical Disease Activity Index remission rate increased from 25.0% to 38.9%. Serious adverse events were identified in two patients. CONCLUSIONS Oral GC administration was discontinued without deterioration in the rheumatoid arthritis disease control.
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Affiliation(s)
- Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroki Kohno
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Hirofumi Watanabe
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tadahiro Tokunaga
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yusuke Yoshida
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Tomohiro Sugimoto
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Sho Mokuda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Keisuke Oda
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Takaki Nojima
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Eiji Sugiyama
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
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13
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Buttgereit F. Glucocorticoids: surprising new findings on their mechanisms of actions. Ann Rheum Dis 2020; 80:137-139. [PMID: 33162396 DOI: 10.1136/annrheumdis-2020-218798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Frank Buttgereit
- Charité University Medicine, Department of Rheumatology and Clinical Immunology, Berlin, Germany
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14
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Palmowski A, Buttgereit F. Reducing the Toxicity of Long-Term Glucocorticoid Treatment in Large Vessel Vasculitis. Curr Rheumatol Rep 2020; 22:85. [PMID: 33047263 PMCID: PMC7550368 DOI: 10.1007/s11926-020-00961-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 12/14/2022]
Abstract
Purpose While glucocorticoids (GCs) are effective in large vessel vasculitis (LVV), they may cause serious adverse events (AEs), especially if taken for longer durations and at higher doses. Unfortunately, patients suffering from LVV often need long-term treatment with GCs; therefore, toxicity needs to be expected and countered. Recent Findings GCs remain the mainstay of therapy for both giant cell arteritis and Takayasu arteritis. In order to minimize their toxicity, the following strategies should be considered: GC tapering, administration of conventional synthetic (e.g., methotrexate) or biologic (e.g., tocilizumab) GC-sparing agents, as well as monitoring, prophylaxis, and treatment of GC-related AEs. Several drugs are currently under investigation to expand the armamentarium for the treatment of LVV. Summary GC treatment in LVV is effective but associated with toxicity. Strategies to minimize this toxicity should be applied when treating patients suffering from LVV.
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Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin, Berlin, Germany.
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15
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Wang Y, Zhao R, Gu Z, Dong C, Guo G, Li L. Effects of glucocorticoids on osteoporosis in rheumatoid arthritis: a systematic review and meta-analysis. Osteoporos Int 2020; 31:1401-1409. [PMID: 32291467 DOI: 10.1007/s00198-020-05360-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/19/2020] [Indexed: 12/19/2022]
Abstract
We evaluated the effects of glucocorticoids on bone mineral density (BMD), and prevalence of osteoporosis and fracture in rheumatoid arthritis (RA) by meta-analysis. Until June 26, 2019, we conducted a systematic literature search in EMBASE, Web of science, PubMed, and Cochrane Library to obtain BMD and the prevalence of osteoporosis and fracture in glucocorticoid-treated subjects with RA. The BMD of the treatment and control groups were analyzed by meta-analysis (Stata. version 15), and the 95% confidence interval (CI) was calculated. We identified 15 observational studies, including 46,711 RA subjects and 857 healthy controls. The BMD of the lumbar spine (- 0.038 g/cm2; CI, - 0.052, - 0.024) and femoral neck (- 0.017 g/cm2; - 0.030, - 0.003) in RA treated with glucocorticoids were significantly lower than those in RA controls. Compared with healthy control group, the BMD of the lumbar spine (- 0.094 g/cm2; - 0.126, - 0.061) and femoral neck (- 0.097 g/cm2, - 0.109, - 0.085) of RA treated with glucocorticoids decreased more significantly. The prevalence of osteoporosis in whole body, spine, and femur was 38.6% (0.305, 0.466), 32.9% (0.277, 0.381), and 21.7% (0.106, 0.328), respectively. And the prevalence of vertebral fracture was 13.0% (0.058, 0.203). Glucocorticoids may lead to a decline in skeletal health in subjects with RA, especially in vertebral and femoral BMD, compared with normal people or RA without glucocorticoid therapy. Meanwhile, osteoporosis and fractures were also common. Therapeutic measures should be targeted at individuals, which needs further study. Through meta-analysis, we found that glucocorticoids have some negative effects on the bone health of subjects with rheumatoid arthritis. Therefore, when using glucocorticoids to treat rheumatoid arthritis, we should take strategic measures to prevent the decline of bone quality.
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Affiliation(s)
- Y Wang
- Research Center of Clinical Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Department of Nursing, Affiliated Hospital of Nantong University, Nantong, China
| | - R Zhao
- Research Center of Clinical Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Department of Nursing, Affiliated Hospital of Nantong University, Nantong, China
| | - Z Gu
- Research Center of Gerontology and Longevity, Affiliated Hospital of Nantong University, Nantong, China
- Department of Rheumatology, Affiliated Hospital of Nantong University, 20th Xisi Road, Nantong, 226001, Jiangsu Province, People's Republic of China
| | - C Dong
- Research Center of Clinical Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Research Center of Gerontology and Longevity, Affiliated Hospital of Nantong University, Nantong, China
| | - G Guo
- Department of Rheumatology, Affiliated Hospital of Nantong University, 20th Xisi Road, Nantong, 226001, Jiangsu Province, People's Republic of China.
| | - L Li
- Department of Gastroenterology, Affiliated Hospital of Nantong University, 20th Xisi Road, Nantong, 226001, Jiangsu Province, People's Republic of China.
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16
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Palmowski A, Nielsen SM, Buttgereit T, Palmowski Y, Boers M, Christensen R, Buttgereit F. Glucocorticoid-trials in rheumatoid arthritis mostly study representative real-world patients: A systematic review and meta-analysis. Semin Arthritis Rheum 2020; 50:1400-1405. [PMID: 32222381 DOI: 10.1016/j.semarthrit.2020.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/15/2020] [Accepted: 02/25/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Randomized controlled trials (RCTs) are considered the gold standard in clinical research due to credible causality. Their results, however, may not be generalizable to real-world populations. While glucocorticoids (GCs) remain a mainstay of rheumatoid arthritis (RA) treatment, it is unclear whether the results of GC-RCTs are generalizable to current real-world RA patients. METHODS MEDLINE was searched for RCTs and, as comparators, cohort studies (CSs) in RA evaluating systemic GCs. Random-effects meta-analyses were performed for descriptive baseline characteristics (including general demographics, comorbidities, and disease activity) that have been shown to be able to modify the benefit-risk-ratio of various RA therapeutics. These meta-analyses were stratified by study type (RCT and CS). Stratified estimates were subsequently compared. Further sensitivity analyses were performed stratifying by disease duration. RESULTS 56 RCTs (7053 participants) and 10 CSs (14,688 participants) were included. 12 characteristics were reported frequently enough to allow for comparative analysis. In 10/12 characteristics (83%), RCT estimates did not appear to differ from CS estimates. However, RCT participants were younger (-4.7 years [95% CI -7.2 to -2.1]; p < 0.001) and had higher erythrocyte sedimentation rates (11.8 mm/h [5.7 to 17.8]; p < 0.001) than CS participants. Comorbidities could not be assessed due to insufficient reporting. CONCLUSION Our findings suggest that evidence from GC trials in RA is of acceptable generalizability to current real-world patients - especially compared to findings from biologic agents in RA. However, RCT participants were younger than real-world patients, potentially limiting the generalizability of trial results to elderly patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO (CRD42019134675).
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Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany.
| | - Sabrina M Nielsen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, 2000 Frederiksberg, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, 5000 Odense, Denmark
| | - Thomas Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany; Department of Dermatology, Venerology, and Allergology, Charité - University Medicine Berlin, 10117 Berlin, Germany
| | - Yannick Palmowski
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, 10117 Berlin, Germany
| | - Maarten Boers
- Department of Epidemiology and Biostatistics, and Amsterdam Rheumatology and Immunology Center, Amsterdam UMC, Vrije Universiteit Amsterdam, 1007 MB Amsterdam, the Netherlands
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, 2000 Frederiksberg, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, 5000 Odense, Denmark
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Freier D, Strehl C, Buttgereit F. [Oral glucocorticoids : Therapeutic use and treatment monitoring in inflammatory rheumatic diseases]. Hautarzt 2020; 71:139-153. [PMID: 31980858 DOI: 10.1007/s00105-020-04543-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Glucocorticoids (GC) have been proven drug substances in rheumatology for more than 70 years. They act very rapidly in high doses through membrane stabilizing effects. Genomic therapeutic effects of GC even in very low doses are mainly due to inhibition of the functions of the transcription factor nuclear factor kappa B (NFkB), which promotes the synthesis of proinflammatory mediators, adhesion molecules and other regulatory proteins. Indications for the use of GC in high doses in rheumatology are always given when a life-threatening, dangerous or treatment-resistant situation is involved. Lower doses of GC, usually administered orally, are particularly used in rheumatoid arthritis, vasculitis and collagenosis. In clinical practice the general principle is to use the smallest possible effective dose of GC for the shortest possible time in order to achieve the therapeutic effect of GC without running the risk of unacceptably severe side effects.
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Affiliation(s)
- D Freier
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - C Strehl
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
| | - F Buttgereit
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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18
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Freier D, Buttgereit F. [Controlling glucocorticoid treatment in critically ill patients with rheumatism exemplified by systemic lupus erythematosus]. Z Rheumatol 2019; 78:947-954. [PMID: 31410548 DOI: 10.1007/s00393-019-00686-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Infections are one of the most common clinical problems in patients with rheumatic diseases who need to be treated with glucocorticoids in an intensive care unit. To date, there are no recommendations for the standardized control of glucocorticoid treatment in such situations. OBJECTIVE Based on a literature search this paper provides an overview of evidence-based and eminence-based recommendations for the control of glucocorticoid treatment under intensive care conditions using the example of systemic lupus erythematosus. METHODS A systematic literature search was carried out using a MeSH term search in the PubMed database. RESULTS Infections are one of the most common causes for the treatment of patients with rheumatic diseases in intensive care units. In the case of systemic lupus erythematosus it is particularly challenging to distinguish the infection from increased disease activity or to treat the parallel occurrence. Patients in an intensive care unit are exposed to an increased level of physical stress due to the severity of the disease, which is why special attention should be paid to symptoms of adrenocortical insufficiency. Evidence-based recommendations for prophylaxis of an adrenal crisis only exist in relation to perioperative procedures and not for the situation of severe infections. CONCLUSION The use of glucocorticoids in systemic lupus erythematosus is often chronic and there is an increased risk of infections. In the case of infections (or simultaneous disease flare) adequate anti-infective treatment should be administered, the treatment with glucocorticoids should be adjusted accordingly and symptoms of adrenocortical insufficiency should simultaneously be looked for.
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Affiliation(s)
- D Freier
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - F Buttgereit
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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