The Use of Glucocorticoids by Rheumatologic Patients Before Attending a Specialized Department in México

Are Target Urate and Remission Possible in Severe Gout? A Five-year Cohort Study

OBJECTIVE

Determine the proportion of patients achieving target serum urate (SU), defined as < 6 mg/dl for patients with non-severe gout and < 5 mg/dl for patients with severe gout, as well as the proportion of patients achieving remission after 5 years of followup.

METHODS

Patients from the Gout Study Group (GRESGO) cohort were evaluated at 6-month intervals. Demographic and clinical data were obtained at baseline. Visits included assessments of serum urate, flares, tophus burden, health-related quality of life using the EQ-5D, activity limitations using the Health Assessment Questionnaire adapted for gout, and pain level and patient's global assessment using visual analog scales. Treatment for gout and associated diseases was prescribed according to guidelines and available drugs.

RESULTS

Of 500 patients studied, 221 had severe gout (44%) and 279 had non-severe gout (56%) at baseline. No significant differences were observed across the study in percentages of severe gout versus non-severe gout patients achieving SU 6 mg/dl or 5 mg/dl. The highest proportion of patients achieving target SU (50-70%) and remission (39%) were found after 3-4 years of followup. In the fifth year, these proportions decreased and 28% of the patients were in remission, but only 40 patients remained in the study. None of the patients with severe gout achieved remission.

CONCLUSION

In patients with severe gout, target SU was hard to achieve and remission was not possible. The main obstacles for target SU and gout remission include poor medication adherence, persistent tophi, and loss to followup.

Bone safety of low-dose glucocorticoids in rheumatic diseases

Glucocorticoids are widely used internationally for the treatment of inflammatory disease, such as rheumatoid arthritis (RA). Although the benefit of glucocorticoids in RA on both disease activity and severity are well known, there remain unanswered questions about the overall bone safety of chronic low-dose glucocorticoids in RA. Debate exists about the merits of glucocorticoids for bone health on the basis of their benefits in promoting activity and reducing proinflammatory cytokines. Overall current evidence supports the view that bone loss is a disease related both to RA and to glucocorticoid use independently. Calcium and vitamin D, along with prescription antiosteoporosis therapies, particularly bisphosphonates and teriparatide, play an important role in stabilizing bone mineral density and potentially lowering spinal fracture risk at the spine. International guidelines provide pathways for appropriate prevention of glucocorticoid-induced osteoporosis (GIOP). Despite the evidence and these guidelines, many patients do not receive adequate management to prevent GIOP.

[Comparison of the severity index in Cushing's syndrome between patients with endogenous and iatrogenic disease]

Cushing's syndrome (CS) is a rare condition that is most often secondary to glucocorticoid (GC) intake. Definitive data on the distinction between endogenous CS (ECS) and yatrogenic (YCS) have not been published.

OBJECTIVE

To compare the severity index in Cushing's syndrome (SICS) score in the two etiologies, endogenous and yatrogenic, and identify which clinical parameters of the SICS are the most frequent and representative of CS.

MATERIAL AND METHODS

We performed an observational, descriptive and cross-sectional study. The ECS group included men and women with a diagnosis of endogenous hypercortisolism, with measurement of adrenocorticotropin hormone (ACTH) and absence of causes of pseudo-Cushing's syndrome. The YCS group included patients with a history of use of high-dose systemic GC, cushingoid facies, absence of causes of pseudo-Cushing's syndrome and no diagnosis of hypertension or diabetes mellitus before the start of GC intake. We investigated the diagnosis of the disease entity causing ECS. In patients with ICS, the characteristics of the GC employed and how these drugs were used were recorded. We calculated daily and cumulative doses in milligrams of prednisone. In all patients, the SICS was applied and the clinical characteristics of the two groups were compared.

RESULTS

We included 20 patients, 10 with YCS and 10 with ECS. There were eight women in the ECS group (80%) and five in the YCS group (50%). The diagnoses in patients with ECS were ACTH-dependent CS in nine and ACTH-independent CS in one. The mean daily dose of prednisone equivalent used by patients with YCS was 13.5mg, and the mean total cumulative dose for all patients with ICS was 9962.5mg. The mean total SICS score for the ECS group was 8.6 and was 3.8 points for the YCS group (p <0.005, 95% CI 3.36-6.23). All patients with ECS had a mean score of 6 or higher whereas none of the patients with ICS scored more than 6 points. Fat distribution, hypertension, diabetes mellitus and gender-related changes were more representative of patients with ECS.

CONCLUSION

SICS scores were higher patients with ECS than in those with ICS. The clinical differences between the two groups may be important.