1
|
Buttgereit F, Palmowski A, Bond M, Adami G, Dejaco C. Osteoporosis and fracture risk are multifactorial in patients with inflammatory rheumatic diseases. Nat Rev Rheumatol 2024; 20:417-431. [PMID: 38831028 DOI: 10.1038/s41584-024-01120-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 06/05/2024]
Abstract
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.
Collapse
Affiliation(s)
- Frank Buttgereit
- Department of Rheumatology and Clinical Immunology at Charité - University Medicine Berlin, Berlin, Germany.
| | - Andriko Palmowski
- Department of Rheumatology and Clinical Immunology at Charité - University Medicine Berlin, Berlin, Germany
- The Parker Institute, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
| | | | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
- Department of Rheumatology and Immunology, Medical University Graz, Graz, Austria
| |
Collapse
|
2
|
Kanatoula DD, Bodner E, Ghoreschi K, Meier K, Solimani F. Non-biologic immunosuppressive drugs for inflammatory and autoimmune skin diseases. J Dtsch Dermatol Ges 2024; 22:400-421. [PMID: 38259085 DOI: 10.1111/ddg.15270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/08/2023] [Indexed: 01/24/2024]
Abstract
Non-biologic immunosuppressive drugs, such as azathioprine, dapsone or methotrexate are fundamental treatment options for a wide range of autoimmune and chronic inflammatory skin diseases. Some of these drugs were initially used for malignancies (e.g., azathioprine or methotrexate) or infectious diseases (e.g., hydroxychloroquine or dapsone) but are nowadays mostly used for their immunosuppressive/immunomodulating action. Although dermatologists have years of clinical experience with these drugs, some of the mechanisms of action are not fully understood and are the subject of research. Although these drugs are commonly used, lack of experience or knowledge regarding their safety profiles and management leads to skepticism among physicians. Here, we summarize the mechanism of action and detailed management of adverse effects of the most commonly used immunosuppressive drugs for skin diseases. Furthermore, we discuss the management of these drugs during pregnancy and breastfeeding, as well as their interaction and handling during vaccination.
Collapse
Affiliation(s)
- Danai Dionysia Kanatoula
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Euna Bodner
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Kamran Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Katharina Meier
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Farzan Solimani
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Clinician Scientist Program, Berlin, Germany
| |
Collapse
|
3
|
Kanatoula DD, Bodner E, Ghoreschi K, Meier K, Solimani F. Nicht-Biologika-Immunsuppressiva bei entzündlichen und autoimmunen Hautkrankheiten: Non-biologic immunosuppressive drugs for inflammatory and autoimmune skin diseases. J Dtsch Dermatol Ges 2024; 22:400-423. [PMID: 38450929 DOI: 10.1111/ddg.15270_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 09/08/2023] [Indexed: 03/08/2024]
Abstract
ZusammenfassungNicht‐Biologika‐Immunsuppressiva wie Azathioprin, Dapson oder Methotrexat sind grundlegende Behandlungsmöglichkeiten für ein breites Spektrum von Autoimmunerkrankungen und chronisch‐entzündlichen Hauterkrankungen. Einige dieser Medikamente wurden ursprünglich bei malignen Erkrankungen (zum Beispiel Azathioprin oder Methotrexat) oder Infektionskrankheiten (zum Beispiel Hydroxychloroquin oder Dapson) eingesetzt, werden aber heute hauptsächlich wegen ihrer immunsuppressiven/immunmodulierenden Wirkung verwendet. Obwohl Dermatologen über jahrelange klinische Erfahrung mit diesen Arzneimitteln verfügen, sind einige der Wirkmechanismen noch nicht vollständig geklärt und noch Gegenstand der Forschung. Obwohl diese Medikamente häufig eingesetzt werden, führen mangelnde Erfahrung oder fehlendes Wissen über ihre Sicherheitsprofile und ihr Management zu einer skeptischen Haltung bei den Ärzten. Hier fassen wir den Wirkmechanismus und das detaillierte Management der Nebenwirkungen der am häufigsten verwendeten immunsuppressiven Medikamente für Hautkrankheiten zusammen. Darüber hinaus diskutieren wir den Umgang mit diesen Medikamenten während der Schwangerschaft und Stillzeit sowie ihre Wechselwirkung und Handhabung im Zusammenhang mit Impfungen.
Collapse
Affiliation(s)
- Danai Dionysia Kanatoula
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Euna Bodner
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Kamran Ghoreschi
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Katharina Meier
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
| | - Farzan Solimani
- Abteilung für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin
- BIH Biomedical Innovation Academy, Berlin Institute of Health, Charité - Universitätsmedizin Berlin
| |
Collapse
|
4
|
Palmowski A, Pankow A, Terziyska K, Nielsen SM, Christensen R, Bliddal H, Boyadzhieva Z, Buttgereit F. 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. Semin Arthritis Rheum 2024; 64:152349. [PMID: 38100900 DOI: 10.1016/j.semarthrit.2023.152349] [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: 09/18/2023] [Revised: 11/28/2023] [Accepted: 12/05/2023] [Indexed: 12/17/2023]
Abstract
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.
Collapse
Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Germany; Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark.
| | - Anne Pankow
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Germany
| | - Kalina Terziyska
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Germany
| | - Sabrina M Nielsen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark; Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Denmark
| | - Henning Bliddal
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Denmark
| | - Zhivana Boyadzhieva
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Germany
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Pofi R, Caratti G, Ray DW, Tomlinson JW. Treating the Side Effects of Exogenous Glucocorticoids; Can We Separate the Good From the Bad? Endocr Rev 2023; 44:975-1011. [PMID: 37253115 PMCID: PMC10638606 DOI: 10.1210/endrev/bnad016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/25/2023] [Accepted: 05/26/2023] [Indexed: 06/01/2023]
Abstract
It is estimated that 2% to 3% of the population are currently prescribed systemic or topical glucocorticoid treatment. The potent anti-inflammatory action of glucocorticoids to deliver therapeutic benefit is not in doubt. However, the side effects associated with their use, including central weight gain, hypertension, insulin resistance, type 2 diabetes (T2D), and osteoporosis, often collectively termed iatrogenic Cushing's syndrome, are associated with a significant health and economic burden. The precise cellular mechanisms underpinning the differential action of glucocorticoids to drive the desirable and undesirable effects are still not completely understood. Faced with the unmet clinical need to limit glucocorticoid-induced adverse effects alongside ensuring the preservation of anti-inflammatory actions, several strategies have been pursued. The coprescription of existing licensed drugs to treat incident adverse effects can be effective, but data examining the prevention of adverse effects are limited. Novel selective glucocorticoid receptor agonists and selective glucocorticoid receptor modulators have been designed that aim to specifically and selectively activate anti-inflammatory responses based upon their interaction with the glucocorticoid receptor. Several of these compounds are currently in clinical trials to evaluate their efficacy. More recently, strategies exploiting tissue-specific glucocorticoid metabolism through the isoforms of 11β-hydroxysteroid dehydrogenase has shown early potential, although data from clinical trials are limited. The aim of any treatment is to maximize benefit while minimizing risk, and within this review we define the adverse effect profile associated with glucocorticoid use and evaluate current and developing strategies that aim to limit side effects but preserve desirable therapeutic efficacy.
Collapse
Affiliation(s)
- Riccardo Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - Giorgio Caratti
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| | - David W Ray
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Oxford Kavli Centre for Nanoscience Discovery, University of Oxford, Oxford OX37LE, UK
| | - Jeremy W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford OX3 7LE, UK
| |
Collapse
|
7
|
Boers M. Viewpoint: Glucocorticoids in the treatment of rheumatoid arthritis: points to (re)consider. Rheumatology (Oxford) 2023; 62:3534-3537. [PMID: 37338537 PMCID: PMC10629782 DOI: 10.1093/rheumatology/kead309] [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: 05/10/2023] [Revised: 06/07/2023] [Accepted: 06/10/2023] [Indexed: 06/21/2023] Open
Abstract
Glucocorticoids (prednisone) are essential in the treatment of RA and other autoimmune diseases. They are widely used, but treatment guidelines advise against. This viewpoint article explains why and suggests a way forward.
Collapse
Affiliation(s)
- Maarten Boers
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Barbulescu A, Sjölander A, Delcoigne B, Askling J, Frisell T. Glucocorticoid exposure and the risk of serious infections in rheumatoid arthritis: a marginal structural model application. Rheumatology (Oxford) 2023; 62:3391-3399. [PMID: 36821426 PMCID: PMC10547528 DOI: 10.1093/rheumatology/kead083] [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: 11/05/2022] [Revised: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE Observational studies have reported an increased risk of infections associated with glucocorticoids in RA, not supported by evidence from randomized controlled trials. Inappropriately accommodating time-varying exposure and confounding in observational studies might explain the conflicting results. Therefore, we compared the incidence of serious infections between different oral glucocorticoid dose patterns over three years in a prospective inception cohort, adjusting for time-varying confounders in marginal structural models. METHODS We included 9654 newly diagnosed RA patients from the Swedish Rheumatology Quality Register between 2007-2018 and followed them for three years after the first rheumatology visit. Follow-up was divided into 90-day periods. A mean oral prednisone daily dose was calculated for each period and categorized into 'no use', 'low' (≤10 mg/day) and 'high' (>10 mg/day) doses. The incidence of serious infections (hospitalization for infection) over follow-up periods was modelled by pooled logistic regression allowing separate effects for recent and past exposure. RESULTS An increased incidence of serious infections was associated with higher compared with lower doses and with more recent compared with past glucocorticoid exposure. Over 3 years of follow-up, the marginal structural models predicted one additional serious infection for every 83 individuals treated with low GC doses for the first 6 months, and for every 125 individuals treated with high GC doses for the first 3 months, compared with no GC use. CONCLUSION Our results broadly agree with previous observational studies showing a dose dependent increased risk of infection associated with (recent) use of oral glucocorticoids.
Collapse
Affiliation(s)
- Andrei Barbulescu
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Arvid Sjölander
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Bénédicte Delcoigne
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Johan Askling
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Rheumatology, Theme Inflammation and Ageing, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Frisell
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
9
|
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.
Collapse
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.)
| |
Collapse
|
10
|
Gordeev AV, Matyanova EV, Galushko EA. [Long-term use of glucocorticoids in patients with active rheumatoid arthritis: therapeutic "freeze frame"]. TERAPEVT ARKH 2023; 95:380-385. [PMID: 38158989 DOI: 10.26442/00403660.2023.05.202196] [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: 07/16/2023] [Accepted: 07/16/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND In Russia, as well as throughout the world, the use of glucocorticoids (GC) in the treatment of rheumatoid arthritis (RA) is widespread, often going beyond the recommendations for both duration and dose regimen, which makes it relevant to study the long-term consequences of such a "wrong" (EULAR, 2022) use of GC in RA therapy. MATERIALS AND METHODS Of 1143 patients with active RA (ACR/EULAR 2010), two groups were formed: A (n=782) RA patients with more than 6 months of experience with systemic GC; group B (n=245) - no experience of taking GC. The cumulative disease index (CIRS) was used to assess the comorbidity profile. RESULTS Patients in group A were older (p<0.0001), with a longer duration of RA (p=0.0004) and more often with IV radiological stage (p=0.02). With comparable (DAS28) RA activity, the D2T variant of RA was more often detected in them (p=0.036). RA therapy in group A was characterized by a large number of used disease-modifying anti-rheumatic drugs (p=0.0003), more frequent development of methotrexate-induced hepatitis (p=0.03). In group A, the time interval between the onset of RA and the initiation of biological therapy was longer (p=0.0001) and directly correlated with the duration of GC therapy (Rs=0.38) with a comparable qualitative structure of the used b/tsDMARDs. In the same group, tuberculosis, hypertension, chronic kidney disease, cataract and osteoporosis (p<0.05) and its complications were diagnosed significantly more often with a comparable frequency of cardiovascular disease, diabetes, and gastrointestinal lesions. In group A, a higher CIRS multimorbidity index was detected, and the CIRS severity index was lower than in group B (p<0.05). CONCLUSION Long-term use of GC did not lead to a decrease in disease activity, inhibition of radiographic progression, delayed the timely administration of b/tsDMARDS and was accompanied by an increase in the multimorbid load.
Collapse
|
11
|
Palmowski A, Boyadzhieva Z, Nielsen SM, Muche B, Hermann S, Boers M, Bliddal H, Christensen R, Wiebe E, Buttgereit F. Sex and age do not modify the association between glucocorticoids and bone mineral density in patients with rheumatoid arthritis: a cross-sectional study. Arthritis Res Ther 2023; 25:98. [PMID: 37287080 DOI: 10.1186/s13075-023-03083-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/02/2023] [Indexed: 06/09/2023] Open
Abstract
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.
Collapse
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, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
| | - Zhivana Boyadzhieva
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sabrina M Nielsen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Department of Clinical Research, Research Unit of Rheumatology, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Burkhard Muche
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sandra Hermann
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maarten Boers
- Department of Epidemiology & Data Science, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Henning Bliddal
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Department of Clinical Research, Research Unit of Rheumatology, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Edgar Wiebe
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
12
|
van Ouwerkerk L, Boers M, Emery P, de Jong PH, Landewé RB, Lems W, Smolen JS, Verschueren P, Huizinga TW, Allaart CF, Bergstra SA. Individual patient data meta-analysis on continued use of glucocorticoids after their initiation as bridging therapy in patients with rheumatoid arthritis. Ann Rheum Dis 2023; 82:468-475. [PMID: 36526336 PMCID: PMC10086274 DOI: 10.1136/ard-2022-223443] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/05/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES To investigate whether patients with rheumatoid arthritis (RA) can discontinue glucocorticoids (GC) after GC 'bridging' in the initial treatment step and to identify factors that may affect this. METHODS Data from 7 clinical trial arms (with 1653 patients) that included a GC bridging schedule, previously identified in a systematic literature search, were combined in an individual patient data meta-analysis. Outcomes were GC use (yes/no) at predefined time points (1/3/6/12/18 months after bridging had ended), cumulative GC dose and continuous (≥3 months) GC use after bridging had ended. Age, sex, ACPA status, initial GC dose, duration of bridging schedule, oral versus parenteral GC administration and initial co-treatment were univariably tested with each outcome. RESULTS The probability of using GC 1 month after bridging therapy had ended was 0.18, decreasing to 0.07 from 6 until 18 months after bridging had ended. The probability of continuous GC use after bridging had ended was 0.18 at 1 year and 0.30 at 2 years of follow-up. In oral GC bridging studies only, the probabilities of later and continuous GC use and the cumulative GC doses were higher compared to the combined analyses with also parenteral GC bridging studies included. A higher initial dose and a longer GC bridging schedule were associated with higher cumulative GC doses and more patients on GC at 18 months after bridging had ended. CONCLUSIONS Based on these RA clinical trial arms with an initial GC bridging schedule, the probability of subsequent ongoing GC use following bridging is low.
Collapse
Affiliation(s)
- Lotte van Ouwerkerk
- Department of Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Maarten Boers
- Epidemiology & Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Rheumatology and Immunology Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Pascal Hp de Jong
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert Bm Landewé
- Rheumatology and Immunology Center, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Willem Lems
- Rheumatology and Immunology Center, Amsterdam UMC, Amsterdam, The Netherlands
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Wien, Austria
| | - Patrick Verschueren
- Division of Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Tom Wj Huizinga
- Department of Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Sytske Anne Bergstra
- Department of Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
van Ouwerkerk L, Palmowski A, Nevins IS, Buttgereit F, Verschueren P, Smolen JS, Landewé RB, Bijlsma JJ, Kerschbaumer A, Westhovens R, Huizinga TW, Allaart CF, Bergstra SA. Systematic literature review of observational cohorts and clinical trials into the success rate of glucocorticoid discontinuation after their use as bridging therapy in patients with rheumatoid arthritis. Ann Rheum Dis 2022; 81:937-943. [PMID: 35470162 DOI: 10.1136/annrheumdis-2022-222338] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/14/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the success rate of glucocorticoid (GC) discontinuation during follow-up in observational cohorts and clinical trials using temporary GC as part of initial therapy ('bridging') in newly diagnosed patients with rheumatoid arthritis (RA). METHODS Systematic literature searches were conducted to identify observational cohorts and clinical trials including patients with RA treated with initial GC bridging therapy, defined as discontinuation of GC within 1 year. Patient percentages still using GC were considered the reverse of successful discontinuation. Random effects meta-analyses were performed stratified by time point. RESULTS The scoping literature search for observational cohort studies could not identify studies answering the research question. The literature search for clinical trials identified 7160 abstracts, resulting in 10 included studies, with varying type and dose of GC and varying tapering schedules, of which 4 reported sufficient data on GC discontinuation or use after the bridging phase. The pooled proportion of patients who were still or again using GC was 22% (95% CI 8% to 37%, based on four trials) at 12 months and 10% at 24 months (95% CI -1 to 22, based on two trials). Heterogeneity was substantial (I²≥65%). CONCLUSION The success rate of GC discontinuation after bridging as part of initial treatment of RA has been described in a limited number of studies. Reports on observational cohorts did not answer the research question. In clinical trials, protocolised discontinuation was mostly successful, although 22% of the patients who started GC bridging therapy still or again used GC at 12 months, and 10% at 24 months.
Collapse
Affiliation(s)
| | - Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Isabell S Nevins
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | | | - Josef S Smolen
- Rheumatology, Medical University of Vienna, Wien, Austria
| | - Robert Bm Landewé
- Amsterdam Rheumatology Center, AMC, Amsterdam, The Netherlands.,Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
| | - Johannes Jw Bijlsma
- Department of Rheumatology & Clinical Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - René Westhovens
- Rheumatology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Tom Wj Huizinga
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Cornelia F Allaart
- Rheumatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | | |
Collapse
|
15
|
Pelechas E, Drosos AA. State-of-the-art glucocorticoid-targeted drug therapies for the treatment of rheumatoid arthritis. Expert Opin Pharmacother 2022; 23:703-711. [PMID: 35313795 DOI: 10.1080/14656566.2022.2049238] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Glucocorticoids are steroid hormones broadly used for the treatment of several inflammatory and autoimmune diseases among other numerous indications, including rheumatoid arthritis. AREAS COVERED For the purposes of this article, the authors have performed an extensive review of the literature to present the latest studies on glucocorticoid use in rheumatoid arthritis. They also provide the reader with their expert perspectives on future developments. EXPERT OPINION The authors do not anticipate that glucocorticoids with be replaced in the near future by newer drugs. As such, rheumatologists should be fully aware of the possible side-effects and educate appropriately their patients to recognize and report them. Newer formulations, such as the liposomal/nanoparticle-based treatments, will result in less pronounced adverse effects, but the input of clinical experience along with the current recommendations for the glucocorticoid use will benefit both clinicians and patients with rheumatoid arthritis.
Collapse
Affiliation(s)
- Eleftherios Pelechas
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| | - Alexandros A Drosos
- Rheumatology Clinic, Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
| |
Collapse
|
16
|
Andersen KM, Schieir O, Valois MF, Bartlett SJ, Bessette L, Boire G, Haraoui B, Hazlewood G, Hitchon C, Keystone EC, Pope J, Tin D, Throne JC, Bykerk VP. A Bridge Too Far? Real-World Practice Patterns of Early Glucocorticoid Use in the Canadian Early Arthritis Cohort. ACR Open Rheumatol 2021; 4:57-64. [PMID: 34708574 PMCID: PMC8754017 DOI: 10.1002/acr2.11334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/05/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To describe patterns of glucocorticoid use in a large real-world cohort with early rheumatoid arthritis (RA) and assess the impact on disease activity and treatment. METHODS Data are from adults with new RA (≤1 year) recruited to the Canadian Early Arthritis Cohort (CATCH) and are stratified on the basis of whether a person was prescribed oral glucocorticoids within 3 months of study entry. Disease activity was compared over 24 months. Mixed-effects logistic regression was used for adjusted odds ratios (aORs) of escalation to biologics separately for 12 and 24 months, with random effects terms to account for prescribing patterns clustering by study site. RESULTS Among 1891 persons, 30% received oral steroids. Users were older, were less often employed, and had shorter disease duration and higher disease activity. Disease activity improved over time, with early glucocorticoid users starting at higher levels of disease activity. Participants with early oral glucocorticoids were more likely to be on a biologic at 12 months (aOR = 2.4; 95% confidence interval [CI], 1.5-3.7) and 24 months (aOR = 1.9; 95% CI, 1.3-3.0). Despite Canadian clinical practice guidelines to limit corticosteroid use to short-term or 'bridge' therapy, 30% of patients who used oral glucocorticoids still used them 2 years later. CONCLUSION Early steroids were prescribed sparingly in CATCH and were often indicative of more active baseline disease as well as the need for progression to biologics.
Collapse
Affiliation(s)
| | | | | | - Susan J Bartlett
- McGill University, Montreal, Quebec, Canada, and Johns Hopkins University, Baltimore, Maryland
| | - Louis Bessette
- Centre Hôspitalier Universitairé de Québec-Université Laval, Québec, Québec, Canada
| | - Gilles Boire
- Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Boulos Haraoui
- Institut de Rhumatologie de Montreal, Montreal, Quebec, Canada
| | | | | | | | - Janet Pope
- St. Joseph's Health Care London and University of Western Ontario, London, Ontario, Canada
| | - Diane Tin
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - J Carter Throne
- Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Vivian P Bykerk
- Hospital for Special Surgery and Weill Cornell Medicine, New York City, New York
| | | |
Collapse
|
17
|
Stacy JM, Greenmyer JR, Beal JR, Sahmoun AE, Diri E. The efficacy of low dose short-term prednisone therapy for remission induction in newly diagnosed rheumatoid arthritis patients. Adv Rheumatol 2021; 61:50. [PMID: 34372936 DOI: 10.1186/s42358-021-00205-4] [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: 12/04/2020] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ACR/EULAR recommendations endorse the use of glucocorticoids (GCs) for rheumatoid arthritis (RA) patients' flares and as a bridge to a DMARD. However, the recommendation of low dose short-term monotherapy with (GCs) remains open to the discretion of the clinician. The aim of this study was to assess whether a short-term use of low dose prednisone monotherapy was effective in inducing remission in newly diagnosed RA patients. METHODS A retrospective analysis of patients newly diagnosed with RA at a Community Health Center in North Dakota was performed based on the ACR/EULAR RA classification criteria. Demographic and clinical data were abstracted from patients' medical charts. Patients treated with (< 10 mg/day) of prednisone up to 6 months were included. Response to prednisone was analyzed according to pre- and post-treatment DAS28-ESR score and EULAR response criteria. RESULTS Data on 201 patients were analyzed. The mean prednisone dose was 8 mg/day (range: 5-10; SD = 1.2) and the mean treatment duration was 42.2 days (12-177; 16.9). Disease severity significantly improved from baseline to follow-up for: tender joint count (8.6 ± 4.8 vs. 1.5 ± 3.3; P < 0.001), swollen joint count (6.2 ± 5.0 vs. 1.4 ± 3.0; P < 0.001), and visual analog pain score (4.8 ± 2.6 vs. 2.1 ± 2.5; P < 0.001). DAS28-ESR disease severity significantly improved from baseline to follow-up: (5.1 ± 1.2 vs. 2.7 ± 1.3; P < 0.001). Per EULAR response criteria, 69.7% of patients showed good response to treatment and 20.4% showed moderate response. 54.2% of patients reached remission. CONCLUSION Short-term use of low dose prednisone monotherapy induced disease remission and improved clinical severity of RA in the majority of newly diagnosed patients.
Collapse
Affiliation(s)
- John M Stacy
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Jacob R Greenmyer
- University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - James R Beal
- Department of Family and Community Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA
| | - Abe E Sahmoun
- Department of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Forks, ND, USA
| | - Erdal Diri
- Division of Rheumatology, Trinity Medical Group, Minot, ND, USA.
| |
Collapse
|
18
|
Roubille C, Coffy A, Rincheval N, Dougados M, Flipo RM, Daurès JP, Combe B. Ten-year analysis of the risk of severe outcomes related to low-dose glucocorticoids in early rheumatoid arthritis. Rheumatology (Oxford) 2021; 60:3738-3746. [PMID: 33320245 DOI: 10.1093/rheumatology/keaa850] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/14/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To explore the 10-year tolerability profile of glucocorticoids (GC) use in patients with early RA. METHODS Analysis of 10-year outcome from the early arthritis ESPOIR cohort. Patients were stratified in two groups, without or with GC treatment at least once during their follow-up. The primary outcome was a composite of deaths, cardiovascular diseases (CVD), severe infections and fractures. The weighted Cox time-dependent analysis model was used with inverse probability of treatment weighting (IPTW) propensity score method. RESULTS Among the 608 patients [480 women, mean age of 47.5 (12.1) years], 397 (65%) received low-dose GC [median 1.9 mg/day (IQR 0.6-4.2), mean cumulative prednisone dose 8468 mg (8376), mean duration 44.6 months (40.1)]. In univariate analysis, over 95 total events (10 deaths, 18 CVDs, 32 fractures and 35 severe infections), patients taking GC experienced more events (n = 71) than those without GC (n = 24) (P =0.035). Highest cumulative exposure of GC (≥8.4 g) was associated with highest risk of occurrence of the primary outcome (24.3%, P =0.007), CVDs (7.9%, P =0.001) and severe infections (9.9%, P =0.024). The risk of events over time was significantly associated with GC, age, hypertension and ESR. The risk associated with GC treatment increased between the first follow-up visit [hazard ratio (HR) at 1 year = 0.46, 95% CI: 0.23, 0.90] and 10 years (HR = 6.83, 95% CI: 2.29, 20.35). CONCLUSION The 10-year analysis of this prospective early RA cohort supports a dose and time-dependent impact of low-dose GC treatment, with a long-term high risk of severe outcomes. TRIAL REGISTRATION (ClinicalTrials.gov Identifier: NCT03666091).
Collapse
Affiliation(s)
- Camille Roubille
- Department of Internal Medicine, CHU Montpellier, Montpellier University, Montpellier, France.,PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Amandine Coffy
- Statistiques, University Institute of Clinical Research EA2415 and Clinique Beausoleil, Montpellier cedex, France
| | - Nathalie Rincheval
- Statistiques, University Institute of Clinical Research EA2415 and Clinique Beausoleil, Montpellier cedex, France.,Rheumatology Department, CHU Montpellier, Montpellier University, Montpellier, France
| | - Maxime Dougados
- Medicine Faculty and Rheumatology B Department, Paris-Descartes University, UPRES-EA 4058; APHP, Cochin Hospital, Paris, France
| | - René-Marc Flipo
- Department of Rheumatology, Roger Salengro Hospital, Lille, France
| | - Jean-Pierre Daurès
- Statistiques, University Institute of Clinical Research EA2415 and Clinique Beausoleil, Montpellier cedex, France
| | - Bernard Combe
- Rheumatology Department, CHU Montpellier, Montpellier University, Montpellier, France
| |
Collapse
|
19
|
In the era of disease-modifying antirheumatic drugs, how close are we to treating rheumatoid arthritis without the use of glucocorticoids? Rheumatol Int 2021; 41:1915-1924. [PMID: 34226947 DOI: 10.1007/s00296-021-04939-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
We wanted to see how close we could get to our goal of treating rheumatoid arthritis (RA) without the use of glucocorticoids (GCs) in the disease-modifying antirheumatic drugs (DMARDs) era using real-life data. Established in 2017, the TReasure database is a web-based, prospective, observational cohort for Turkey. As of May 2019, there were 2,690 RA patients recorded as receiving biologic and targeted synthetic DMARDs (bDMARDs and tsDMARDs) therapy. At the start of the bDMARDs or tsDMARDs, patients with follow-up visits of at least 3 months were registered. At the time of registration and the last visit, doses of GCs were recorded and it was determined if the target dose of ≤ 7.5 mg was achieved. During registration and follow-up, 23.4% of the patients did not receive GCs and 76.5% of the patients received GCs at any time. GCs could be stopped after 59 (25-116) months in 28.4% of these patients, but 71.6% of patients were still using GC. The target GC dose could not be achieved in 18.2% of these patients (n = 352). The rate of continuing to use GC was significantly higher in women, in the elderly, those with rheumatoid factor (RF) positive, with higher Visual Analog Scale (VAS) pain and Disease Activity Score (DAS)-28. The initial GC dose of ≥ 7.5 mg/day was found to be crucial in not reaching the GC target dose (p < 0.001, OR 39.0 (24.1-63.2)). The initial GC dose of ≥ 7.5 mg/day, female gender, age, RF positivity, high DAS28, and VAS pain level were all highly related for GC continuation. Despite the use of DMARDs, our data revealed that we are still far from achieving our goal of treating RA without using steroids.
Collapse
|
20
|
Jin S, Li M, Wang Q, Zeng X, Xia W, Yu W, Guan W, Hsieh E. Bone mineral density and microarchitecture among Chinese patients with rheumatoid arthritis: a cross-sectional study with HRpQCT. Arthritis Res Ther 2021; 23:127. [PMID: 33894786 PMCID: PMC8067377 DOI: 10.1186/s13075-021-02503-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/03/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) are at increased risk of fractures. Although their decline in bone mineral density (BMD) is well-established, data regarding the alterations in bone microarchitecture are limited. In this study, we aimed to evaluate bone microarchitecture, geometry, and volumetric BMD among patients with RA in mainland China using high-resolution peripheral quantitative computed tomography (HRpQCT). METHODS In this cross-sectional study, patients with RA were recruited from the Peking Union Medical College Hospital site of the Chinese Registry of rhEumatoiD arthrITis (CREDIT). Each participant underwent HRpQCT scanning (Scanco XtremeCT II), thoracolumbar X-ray and dual-energy X-ray absorptiometry. The primary outcomes were HRpQCT-related measures at distal radius and tibia. Data regarding demographic features, RA-related characteristics, and history of fragility fractures were collected. Correlation between HRpQCT parameters and potentially related factors were analyzed using linear regression analysis. A group of age- and sex-matched healthy controls was included for comparison. RESULTS A total of 81 patients with RA [69 women, aged 57.9 ± 8.7 years, disease duration 5.7 (IQR 1.4-11.2) years] and 81 matched healthy controls were included. Compared with controls, patients with RA had significantly larger bone area and lower total and trabecular vBMD at both the distal radius and tibia. Lower cortical bone thickness was also shown at the distal tibia. Among patients with RA, advanced age, low BMI, female sex, disease duration, and activity were associated with decreased vBMD and impaired bone microstructure. Female reproductive factors including menopause, late menarche, breast feeding, and early childbirth also showed negative correlation with these parameters. Compared to patients with RA without fractures, patients with fragility fractures (n = 11) showed lower trabecular and cortical vBMD, thinner cortical bone, impaired trabecular microstructure, and a trend of declined bone strength. Current glucocorticoid intake was related to decreased vBMD, trabecular number, increased trabecular separation, and inhomogeneity. CONCLUSIONS In this study, we observed alterations in bone mineral density, geometry, and microarchitecture among patients with RA compared to healthy individuals, which may impair bone strength and lead to increased risk of fractures. Both traditional risk factors for osteoporosis and RA-associated factors need to be considered in the assessment of the bone quality.
Collapse
Affiliation(s)
- Shangyi Jin
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH); Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Weibo Xia
- Department of Endocrinology, Key Laboratory of Endocrinology, National Commission of Health, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Wei Yu
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenmin Guan
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Evelyn Hsieh
- Section of Rheumatology, Allergy and Immunology, Yale School of Medicine, 300 Cedar Street, TAC S-525, P.O. Box 208031, New Haven, CT, 06520-8031, USA.
| |
Collapse
|
21
|
Hua C, Buttgereit F, Combe B. Glucocorticoids in rheumatoid arthritis: current status and future studies. RMD Open 2021; 6:rmdopen-2017-000536. [PMID: 31958273 PMCID: PMC7046968 DOI: 10.1136/rmdopen-2017-000536] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 11/05/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022] Open
Abstract
Since their first use for treating rheumatoid arthritis (RA) in the late 1940s, glucocorticoids (GCs) have been representing a substantial part of the therapeutic arsenal for RA. However, even if GCs are still widely prescribed drugs, their toxicity is discussed controversially, so obtaining consensus on their use in RA is difficult. Hence, the most recent European League Against Rheumatism and American College of Rheumatology recommendations on early arthritis and RA management advocate the use of GCs as adjunct treatment to conventional synthetic disease-modifying antirheumatic drugs, at the lowest dose possible and for the shortest time possible. However, the recommendations remain relatively vague on dose regimens and routes of administration. Here, we describe literature data on which the current recommendations are based as well as data from recent trials published since the drafting of the guidelines. Moreover, we make proposals for daily practice and provide suggestions for studies that could help clarifying the place of GCs in RA management. Indeed, numerous items, including the benefit/risk ratio of low-dose and very low-dose GCs and optimal duration of GCs as bridging therapy, remain on the research agenda, and future studies are needed to guide the next recommendations for RA.
Collapse
Affiliation(s)
- Charlotte Hua
- Rheumatology Department, Nîmes Hospital, EA2415, Montpellier University, Nîmes, France
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin (CCM), Berlin, Germany
| | - Bernard Combe
- Rheumatology Department, Montpellier hospital, UMR 5535, Montpellier University, Montpellier, France
| |
Collapse
|
22
|
Xie W, Huang H, Li G, Hao Y, Gui Y, Wang Y, Deng X, Zhao J, Geng Y, Ji L, Zhang X, Song Z, Zhang Z. Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020. Ann Rheum Dis 2021; 80:997-1003. [PMID: 33811037 DOI: 10.1136/annrheumdis-2021-220112] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/21/2021] [Accepted: 03/23/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To unravel the dynamical trajectory and features of glucocorticoids (GC) tapering and discontinuation in patients with rheumatoid arthritis (RA) commencing GC with concomitant conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). METHODS We used data from longitudinal real-world Treat-to-TARget in RA cohort. Patients with RA who started GC and contaminant csDMARDs therapy were included. The changes in GC dose and disease activity were evaluated. GC discontinuation rate was analysed using Kaplan-Meier analysis. The relapse profile within 6 months after GC discontinuation was also analysed. RESULTS A total of 207 patients with RA were included. During a median follow-up of 38.6 months, 124 patients discontinued GC. The median prednisolone dose of 10 (5-10) mg/day at initiation was reduced by 50% in the first 6 months and then more slowly, to zero by 48 months eventually. The cumulative probabilities of GC discontinuation were 9.7%, 26.6%, 48.0% and 58.6% at month 6, years 1, 2 and 3, with calculated median time to GC cessation of 27 months. In 110 DMARD-naïve patients, the corresponding cumulative probabilities of GC discontinuation were, respectively, 12.7%, 30.0%, 50.9% and 60.6%, with calculated median time to GC cessation of 24 months. Of the 124 patients who discontinued GC, adding other csDMARDs or concomitant csDMARDs increment was documented in 28.2% of them. Approximately half of 124 patients were in clinical remission at GC discontinuation. Within 6 months after GC withdrawal, 79.1% (91/115) of patients maintained relapse free. CONCLUSIONS In patients with RA commencing GC besides csDMARDs, GC is feasibly discontinued with favourable control of disease activity in real-life setting, mostly without short-term flare. But the withdrawal time is far from reaching the recommended time frame, indicating the gap between real-world practice and current guidelines.
Collapse
Affiliation(s)
- Wenhui Xie
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Hong Huang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Guangtao Li
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yanjie Hao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yanni Gui
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yu Wang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Xuerong Deng
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Juan Zhao
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Yan Geng
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - LanLan Ji
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Xiaohui Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhibo Song
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China
| |
Collapse
|
23
|
[Safety aspects of the treatment with glucocorticoids for rheumatoid arthritis]. Z Rheumatol 2021; 80:295-304. [PMID: 33704557 PMCID: PMC7948162 DOI: 10.1007/s00393-021-00972-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2020] [Indexed: 12/15/2022]
Abstract
Glukokortikoide (GC) werden für die initiale Therapie der RA nach wie vor empfohlen – zeitlich befristet und in geringstmöglicher Dosierung. Ihre komplexe Wirkweise geht mit Nebenwirkungen einher, die v. a. in der Dauertherapie oberhalb von 5 mg Prednisolon pro Tag eine Rolle spielen. In diesem Dosisbereich begünstigen sie Osteoporose, Diabetes/Hyperglykämie, kardiovaskuläre Ereignisse und Infektionen und tragen damit zu einer vermehrten Frühsterblichkeit bei. Dabei sind die Risiken der GC-Therapie von patientenbezogenen Faktoren abhängig wie Alter, Komorbidität und Begleitmedikation. Ein negativer Einfluss sehr niedriger Steroiddosen auf das Gesamtüberleben ist möglicherweise bei hoher kumulativer Dosis nachweisbar, die Datenlage ist hier jedoch widersprüchlich. Das Monitoring einer GC-vermittelten Toxizität mithilfe eines validierten Index sollte in Zukunft dazu beitragen, die Vorteile einer steroidsparenden Behandlungsstrategie besser zu beschreiben. Selektiver wirkende Substanzen könnten in Zukunft eine Abkopplung der erwünschten Wirkungen von den Nebenwirkungen ermöglichen.
Collapse
|
24
|
Sapart E, Sokolova T, de Montjoye S, Dierckx S, Nzeusseu A, Avramovska A, Durez P. Should we use glucocorticoid in Early Rheumatoid Arthritis?: Results at 5 years from the ERA UCLouvain Brussels cohort. Rheumatology (Oxford) 2021; 60:5576-5582. [PMID: 33605405 DOI: 10.1093/rheumatology/keab151] [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: 11/13/2020] [Accepted: 02/01/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To evaluate the proportion of patients with ERA who have initiated or not GC, to analyse the baseline characteristics, and to assess the clinical benefit and side effects of GC during 5 years of follow-up. METHODS We included patients with ERA from the UCLouvain Brussels cohort who met the ACR/EULAR 2010 classification criteria and were naïve to cDMARDs. We retrospectively collected patient characteristics prior to the introduction of cDMARDs with or without GC. Efficiency and serious adverse events were analysed at 6, 12, 36 and 60 months. RESULTS Data from 474 eligible ERA patients were collected. 180 patients initiated GC compared with 294 who did not.At baseline, the increased CRP is the main factor that favors the initiation of GC followed by smoking, absence of ACPA, prescription of methotrexate as a monotherapy and age.5 years follow-up of DAS28-CRP, HAQ or VAS pain values did not differ between the two groups.We also analysed a subgroup of 139 patients who received >1 g of prednisolone during the 5 years period. We confirmed the same baseline differences and observed in addition more males and higher DAS-28CRP values. During the 5 years follow up, DAS-28CRP, VAS pain and HAQ remained significantly higher in this subgroup. More severe infections were also reported. CONCLUSION In our ERA cohort, the initiation of GC treatment does not bring additional benefit for the short and long-term control of the disease. GC was more prescribed in seronegative RA patients with a higher level of inflammation. DISCLOSURE STATEMENT the authors declare no conflicts of interest. ETHICS STATEMENT authors declare that the study complies with the Declaration of Helsinki.
Collapse
Affiliation(s)
- Emilie Sapart
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Tatiana Sokolova
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Stéphanie de Montjoye
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | | | - Adrien Nzeusseu
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Aleksandra Avramovska
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - Patrick Durez
- Department of Rheumatology, Cliniques Universitaires Saint-Luc-Université Catholique de Louvain (UCLouvain) - Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| |
Collapse
|
25
|
Burmester GR, Buttgereit F, Bernasconi C, Álvaro-Gracia JM, Castro N, Dougados M, Gabay C, van Laar JM, Nebesky JM, Pethoe-Schramm A, Salvarani C, Donath MY, John MR. Continuing versus tapering glucocorticoids after achievement of low disease activity or remission in rheumatoid arthritis (SEMIRA): a double-blind, multicentre, randomised controlled trial. Lancet 2020; 396:267-276. [PMID: 32711802 DOI: 10.1016/s0140-6736(20)30636-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/19/2020] [Accepted: 03/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with inflammatory diseases, such as rheumatoid arthritis, often receive glucocorticoids, but long-term use can produce adverse effects. Evidence from randomised controlled trials to guide tapering of oral glucocorticoids is scarce. We investigated a scheme for tapering oral glucocorticoids compared with continuing low-dose oral glucocorticoids in patients with rheumatoid arthritis. METHODS The Steroid EliMination In Rheumatoid Arthritis (SEMIRA) trial was a double-blind, multicentre, two parallel-arm, randomised controlled trial done at 39 centres from six countries (France, Germany, Italy, Russia, Serbia, and Tunisia). Adult patients with rheumatoid arthritis receiving tocilizumab and glucocorticoids 5-15 mg per day for 24 weeks or more were eligible for inclusion if they had received prednisone 5 mg per day for 4 weeks or more and had stable low disease activaity, confirmed by a Disease Activity Score for 28 joints-erythrocyte sedimentation rate (DAS28-ESR) of 3·2 or less 4-6 weeks before and on the day of randomisation. Patients were randomly assigned 1:1 to either continue masked prednisone 5 mg per day for 24 weeks or to taper masked prednisone reaching 0 mg per day at week 16. All patients received tocilizumab (162 mg subcutaneously every week or 8 mg/kg intravenously every 4 weeks) with or without csDMARDs maintained at stable doses during the entire 24-week study. The primary outcome was the difference in mean DAS28-ESR change from baseline to week 24, with a difference of more than 0·6 defined as clinically relevant between the continued-prednisone group and the tapered-prednisone group. The trial is registered with ClinicalTrials.gov, NCT02573012. FINDINGS Between Oct 21, 2015, and June 9, 2017, 421 patients were screened and 259 (200 [77%] women and 59 [23%] men) were recruited onto the trial. In all 128 patients assigned to the continued-prednisone regimen, disease activity control was superior to that in all 131 patients assigned to the tapered-prednisone regimen; the estimated mean change in DAS28-ESR from baseline to week 24 was 0·54 (95% CI 0·35-0·73) with tapered prednisone and -0·08 (-0·27 to 0·12) with continued prednisone (difference 0·61 [0·35-0·88]; p<0·0001), favouring continuing prednisone 5 mg per day for 24 weeks. Treatment was regarded as successful (defined as low disease activity at week 24, plus absence of rheumatoid arthritis flare for 24 weeks and no confirmed adrenal insufficiency) in 99 (77%) patients in the continued-prednisone group versus 85 (65%) patients in the tapered-prednisone group (relative risk 0·83; 95% CI 0·71-0·97). Serious adverse events occurred in seven (5%) patients in the tapered-prednisone group and four (3%) patients in the continued-prednisone group; no patients had symptomatic adrenal insufficiency. INTERPRETATION In patients who achieved low disease activity with tocilizumab and at least 24 weeks of glucocorticoid treatment, continuing glucocorticoids at 5 mg per day for 24 weeks provided safe and better disease control than tapering glucocorticoids, although two-thirds of patients were able to safely taper their glucocorticoid dose. FUNDING F Hoffmann-La Roche.
Collapse
MESH Headings
- Administration, Intravenous
- Administration, Oral
- Adult
- Aged
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/therapeutic use
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/ethnology
- Double-Blind Method
- Drug Administration Schedule
- Drug Therapy, Combination
- Female
- France/epidemiology
- Germany/epidemiology
- Glucocorticoids/administration & dosage
- Glucocorticoids/adverse effects
- Glucocorticoids/therapeutic use
- Humans
- Injections, Subcutaneous
- Italy/epidemiology
- Male
- Middle Aged
- Outcome Assessment, Health Care
- Prednisone/administration & dosage
- Prednisone/adverse effects
- Prednisone/therapeutic use
- Remission Induction/methods
- Russia/epidemiology
- Serbia/epidemiology
- Tunisia/epidemiology
Collapse
Affiliation(s)
- Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Free University and Humboldt University of Berlin, Berlin, Germany.
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Free University and Humboldt University of Berlin, Berlin, Germany
| | | | - Jose M Álvaro-Gracia
- Hospital General Universitario Gregorio Marañon, Universidad Complutense de Madrid, Spain
| | - Nidia Castro
- Pharmaceuticals Division, F Hoffmann-La Roche, Basel, Switzerland
| | - Maxime Dougados
- Rheumatology Service, Université Paris-Descartes, Paris, France
| | - Cem Gabay
- Department of Rheumatology, Hôpital Cochin, Geneva University Hospitals and Geneva School of Medicine, Geneva, Switzerland
| | | | | | | | - Carlo Salvarani
- Department of Rheumatology and Clinical Immunology, Università di Modena e Reggio Emilia and Azienda unità sanitaria locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marc Y Donath
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Markus R John
- Pharmaceuticals Division, F Hoffmann-La Roche, Basel, Switzerland
| |
Collapse
|
26
|
Muilu P, Rantalaiho V, Kautiainen H, Virta LJ, Eriksson JG, Puolakka K. First-year drug therapy of new-onset rheumatoid and undifferentiated arthritis: a nationwide register-based study. BMC Rheumatol 2020; 4:34. [PMID: 32637868 PMCID: PMC7333434 DOI: 10.1186/s41927-020-00127-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 03/30/2020] [Indexed: 02/07/2023] Open
Abstract
Background In this retrospective cohort study, we evaluated the drug therapies used for early rheumatoid (RA) and undifferentiated (UA) arthritis patients. Methods From a nationwide register maintained by the Social Insurance Institution, information on sex, date of birth, and date of special medicine reimbursement decision for all new Finnish RA and UA patients between 2011 and 14 were collected, and their DMARD (Disease Modifying Antirheumatic Drug) purchases during the first year after the diagnosis were analyzed. Results A total of 7338 patients with early RA (67.3% female, 68.1% seropositive) and 2433 with early UA (67.8% female) were identified. DMARDs were initiated during the first month after the diagnosis to 92.0% of the patients with seropositive RA, 90.3% with seronegative RA and to 87.7% with UA (p < 0.001). Respectively, 72.1, 63.4, and 42.9% of the patients (p < 0.001) purchased methotrexate; 49.8, 35.9, and 16.0% (p < 0.001) as part of a DMARD combination during the first month. By the end of the first year after the diagnosis, self-injected biologics were purchased by 2.6, 5.3 and 3.1% (p < 0.001) of them. Only 1.4, 2.6 and 3.0% (p < 0.001) of the patients were not receiving any DMARDs. During the first year, 83.4% of the seropositive RA patients had purchased methotrexate, 50.4% sulfasalazine, 72.1% hydroxychloroquine, and 72.6% prednisolone. Conclusions Currently, combination therapy including methotrexate is a common treatment strategy for early seropositive RA in Finland. Despite an easy access to biologics, these drugs are seldom needed during the first year after diagnosis.
Collapse
Affiliation(s)
- Paula Muilu
- Department of Medicine, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland.,Centre for Rheumatic Diseases, Tampere University Hospital, Tampere, Finland
| | - Vappu Rantalaiho
- Centre for Rheumatic Diseases, Tampere University Hospital, Tampere, Finland.,Faculty on Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University Hospital, Kuopio, Finland.,Folkhälsan Research Center, Helsinki, Finland
| | - Lauri J Virta
- Research Department, Social Insurance Institution of Finland, Turku, Finland
| | - Johan G Eriksson
- Folkhälsan Research Center, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland.,Department of Obstetrics and Gynecology, National University Singapore, Yong Loo Lin School of Medicine, Singapore, Singapore.,Singapore Institute for Clinical Sciences (SICS), Agency for Science, Technology and Research (ASTAR), Singapore, Singapore
| | - Kari Puolakka
- Department of Medicine, South Karelia Central Hospital, Lappeenranta, Finland
| |
Collapse
|
27
|
Hua L, Du H, Ying M, Wu H, Fan J, Shi X. Efficacy and safety of low-dose glucocorticoids combined with methotrexate and hydroxychloroquine in the treatment of early rheumatoid arthritis: A single-center, randomized, double-blind clinical trial. Medicine (Baltimore) 2020; 99:e20824. [PMID: 32629668 PMCID: PMC7337402 DOI: 10.1097/md.0000000000020824] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Glucocorticoids (GCs), especially low-dose GCs, are commonly prescribed for rheumatoid arthritis (RA), although the risk/benefit ratio is controversial. A randomized, double-blind clinical trial was performed to evaluate the efficacy and safety of low-dose oral GCs combined with methotrexate (MTX) and hydroxychloroquine (HCQ) in early RA (ERA). METHODS Eighty untreated ERA patients were randomized into the trial (GCs + MTX + HCQ) and control (placebo + MTX + HCQ) groups, for 1-year treatment. Therapeutic evaluation indices were American College of Rheumatology (ACR) 20 of ACR, disease activity score (DAS) 28- erythrocyte sedimentation rate (ESR), visual analog scale scores, joint function, health assessment questionnaire-disability index score, morning stiffness duration, C-reaction protein and ESR. The clinical indicators were evaluated pre-treatment and at 1st, 3th, 6th and 12th month of treatment. The MRI data of single joint (ie, the most swollen joint) for each patient were acquired with a revised OMERACT RAMRIS Scoring System before and after treatment. The correlation analysis was adopted to confirm whether the efficacy of GC treatment is related to the time of RA onset. The side effects (eg, gastrointestinal reactions, liver dysfunction, upper respiratory tract infection, leukocyte reduction) were also monitored. RESULTS At 1st month, 55% and 20% cases in the experimental and control groups achieved ACR20 response, respectively, indicating a significant difference (χ = 16.157, P < .001). This trend continued until 6th month. At 12th month, the number of patients achieved ACR20 response was similar in both groups. At 1st to 6th month, DAS28- ESR scores in the experimental group were significantly lower than control values (all p < .05). The experimental group showed improved inflammation, quality of life and radiological symptoms. Bone erosion remained unchanged in the experimental group, while worsening in control group. Correlation coefficients between RA duration and DAS28-ESR score were 0.496, 0.464, 0.509, and 0.550 at 1st, 3th, 6th, and 12th month, respectively. No differences were found in adverse events between the 2 groups. CONCLUSIONS Low-dose GCs combined with MTX and HCQ significantly achieves disease remission indexed by ACR20 and DAS28-ESR, and improves clinical and radiological outcomes in ERA patients at the early stage, with superiority over placebo + MTX + HCQ, without enhancing adverse reactions.
Collapse
Affiliation(s)
- Li Hua
- Department of Rheumatology
| | | | - Mingliang Ying
- Department of Radiology, Jinhua Municipal Central Hospital, Jinhua Zhejiang, China
| | | | | | | |
Collapse
|
28
|
Berardicurti O, Ruscitti P, Pavlych V, Conforti A, Giacomelli R, Cipriani P. Glucocorticoids in rheumatoid arthritis: the silent companion in the therapeutic strategy. Expert Rev Clin Pharmacol 2020; 13:593-604. [PMID: 32434398 DOI: 10.1080/17512433.2020.1772055] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Glucocorticoids (GCs) are key actors in RA management, despite the increasing number of available drugs. In fact, due to their efficacy and safety, the combination therapy between GCs and conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) is still recommended in the early phase of RA treatment, because improving the long-term results. AREAS COVERED In this paper, we reviewed the role of GCs in RA management, focusing on mechanisms of action as well as the benefit/risk ratio of GCs and newer therapeutic formulations. Furthermore, we analyzed GCs DMARDs proprieties on disease activity and their long-term effects on radiographic damage. We designed a narrative review aimed to provide an overview concerning GCs in RA management. EXPERT OPINION A large amount of evidence supports the use of GCs in RA, especially in the earliest phases of the disease. Besides GCs symptomatic effects due to their strong anti-inflammatory effects, data from several randomized clinical trials have shown a substantial benefit of low-dose GCs in inhibiting the radiographic damage, thus highlighting GCs DMARDs properties. Besides their recognized role in the treatment of early RA, systematic monitoring of adverse events should be recommended to minimize GCs toxicity.
Collapse
Affiliation(s)
- Onorina Berardicurti
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila , L'Aquila, Italy
| | - Piero Ruscitti
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila , L'Aquila, Italy
| | - Viktoriya Pavlych
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila , L'Aquila, Italy
| | - Alessandro Conforti
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila , L'Aquila, Italy
| | - Roberto Giacomelli
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila , L'Aquila, Italy
| | - Paola Cipriani
- Department of Biotechnological and Applied Clinical Sciences, Rheumatology Unit, University of L'Aquila , L'Aquila, Italy
| |
Collapse
|
29
|
Fragility fractures in psoriatic arthritis patients: a matched retrospective cohort study. Clin Rheumatol 2020; 39:3685-3691. [PMID: 32462424 DOI: 10.1007/s10067-020-05074-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 03/20/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare incidental fragility fractures in psoriatic arthritis (PsA) patients with matched controls from a university hospital. METHODS Consecutive PsA patients were matched (age and sex) with controls (1:2). Follow-up began at index date, defined as the date of PsA diagnosis for cases and their respective controls, until the last hospital visit, death or the end of the study (31 December 2017). Electronic medical records were reviewed for osteoporotic fractures. Incidence rates per 100,000 persons-years (PY) of distinct types of fractures after index dates were calculated and compared between groups. A multivariate Cox regression analysis was performed to investigate determinants of fractures. RESULTS Ninety-two PsA patients and 184 controls were included. No difference was found in the overall fracture incidence rate per 100,000 PY between PsA and controls (1020 95% CI 510-1930, vs 870 95% CI 520-1390, p = 0.36). Vertebral fractures were numerically more frequent in PsA patients with an incidence rate of 1020 (95% CI 510-1930) per 100,000 PY versus 460 (95% CI 240-920), per 100,000 PY in the control group but it did not reach statistical significance (p = 0.06). In the Cox regression analysis, after adjusting for bisphosphonate use, only age (HR 1.10, 1.05-1.16, p < 0.001) and female sex (HR 3.94, 1.11-13.91, p = 0.03) were associated with fractures while PsA diagnosis and use of glucocorticoids were not. CONCLUSION In this cohort of PsA patients, no overall increased risk of fractures was found in comparison with matched controls. Key Points • PsA could have different effects on bone, leading to confusing results in bone densitometry readings contributing to the difficulty in establishing the real prevalence of OP in PsA. • Vertebral fractures were more frequent in PsA patients compared to controls, but it did not reach statistical significance. No difference was found in the overall fracture incidence rate.
Collapse
|
30
|
Views on glucocorticoid therapy in rheumatology: the age of convergence. Nat Rev Rheumatol 2020; 16:239-246. [PMID: 32076129 DOI: 10.1038/s41584-020-0370-z] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2020] [Indexed: 12/16/2022]
Abstract
After decades of sometimes fierce debate about the advantages and disadvantages of glucocorticoids, an age of convergence has been reached. Current recommendations for the management of diseases such as rheumatoid arthritis (RA), polymyalgia rheumatica and large vessel vasculitis reflect the current consensus that as much glucocorticoid as necessary, but as little as possible, should be used. Over the past few years, a range of glucocorticoid-sparing strategies have been developed, as have tools to improve the management of this therapy. A comprehensive view of glucocorticoid-induced osteoporosis has also emerged that recognizes that bone fragility is not solely determined by the dose and duration of glucocorticoid treatment. Nevertheless, open questions remain around whether long-term use of very low doses of glucocorticoids is a realistic option for patients with RA and whether the search for innovative glucocorticoids or glucocorticoid receptor ligands with improved benefit-to-risk ratios will ultimately be successful.
Collapse
|
31
|
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.
Collapse
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
| |
Collapse
|
32
|
|
33
|
Hollan I, Ronda N, Dessein P, Agewall S, Karpouzas G, Tamargo J, Niessner A, Savarese G, Rosano G, Kaski JC, Wassmann S, Meroni PL. Lipid management in rheumatoid arthritis: a position paper of the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 6:104-114. [DOI: 10.1093/ehjcvp/pvz033] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/29/2019] [Accepted: 08/08/2019] [Indexed: 12/24/2022]
Abstract
Abstract
Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity, partly due to alterations in lipoprotein quantity, quality and cell cholesterol trafficking. Although cardiovascular disease significantly contributes to mortality excess in RA, cardiovascular prevention has been largely insufficient. Because of limited evidence, optimal strategies for lipid management (LM) in RA have not been determined yet, and recommendations are largely based on expert opinions. In this position paper, we describe abnormalities in lipid metabolism and introduce a new algorithm for estimation of cardiovascular risk (CVR) and LM in RA. The algorithm stratifies patients according to RA-related factors impacting CVR (such as RA activity and severity and medication). We propose strategies for monitoring of lipid parameters and treatment of dyslipidaemia in RA (including lifestyle, statins and other lipid-modifying therapies, and disease modifying antirheumatic drugs). These opinion-based recommendations are meant to facilitate LM in RA until more evidence is available.
Collapse
Affiliation(s)
- Ivana Hollan
- Lillehammer Hospital for Rheumatic Diseases, M. Grundtvigs veg 6, 2609 Lillehammer, Norway
- Department of Medicine, Division of Cardiovascular Medicine, 75 Francis Street, Boston, MA, 02115, USA
| | | | - Patrick Dessein
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, 7 York Road, Parktown, Johannesburg 2193, South Africa
- Department of Rheumatology, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Jubilee Road, Parktown, Johannesburg 2196, South Africa
- Rheumatology Unit, Free University Hospital, Faculty of Medicine and Pharmacy, Free University, Laarbeeklaan 103, Jette, Brussels 1090, Belgium
| | - Stefan Agewall
- Department of Cardiology, Oslo University Hospital Ullevål, Kirkeveien 166, 0450 Oslo, Norway
| | - George Karpouzas
- Department of Medicine, Division of Rheumatology, Los Angeles Biomedical Research Institute, Harbor-UCLA Medical Center, 1124 W Carson Street, Building E4-R17A,Torrance, CA 90502, USA
| | - Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Plaza de Ramón y Cajal s/n, 28040, Madrid, Spain
| | - Alexander Niessner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Gianluigi Savarese
- Norrbacka, S1:02, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Roma, Via della Pisana 249, 00163 Roma, Italy
| | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's, University of London, Cranmer Terrace, London SW17 ORE, UK
| | - Sven Wassmann
- Cardiology Pasing, Institutstr. 14, 81241 Munich, Germany
- Department of Cardiology, University of the Saarland, Kirrbergerstr. 100, 66421 Homburg/Saar, Germany
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, Istituto Auxologico Italiano, Via Ariosto, 14, 20145 Milan, Italy
| |
Collapse
|
34
|
Impact of Adverse Events Associated With Medications in the Treatment and Prevention of Rheumatoid Arthritis. Clin Ther 2019; 41:1376-1396. [DOI: 10.1016/j.clinthera.2019.04.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/28/2019] [Accepted: 04/10/2019] [Indexed: 02/07/2023]
|
35
|
Boeters DM, Burgers LE, Sasso EH, Huizinga TWJ, van der Helm-van Mil AHM. ACPA-negative RA consists of subgroups: patients with high likelihood of achieving sustained DMARD-free remission can be identified by serological markers at disease presentation. Arthritis Res Ther 2019; 21:121. [PMID: 31088574 PMCID: PMC6518725 DOI: 10.1186/s13075-019-1902-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/22/2019] [Indexed: 12/28/2022] Open
Abstract
Background Disease-modifying antirheumatic drug (DMARD)-free remission, the sustained absence of synovitis after DMARD cessation, is increasingly achievable, especially in autoantibody-negative rheumatoid arthritis (RA). However, underlying mechanisms are unknown and patient subgroups that achieve this outcome are insufficiently characterized. We evaluated whether serological biomarkers at disease onset, as measured within the multi-biomarker disease activity (MBDA) score, are differently expressed in RA patients who achieve sustained DMARD-free remission. Methods Two hundred ninety-nine RA patients were evaluated for achievement of sustained DMARD-free remission during a median follow-up of 4.3 years. Twelve biomarkers, as included in the MBDA score, were determined from the serum obtained at disease onset. Patients were categorized as having a low (< 30), moderate (30–44) or high (> 44) score. Analyses were stratified for anti-citrullinated protein antibodies (ACPA) based under the assumption that ACPA-positive and ACPA-negative RA are different disease entities. Results Twenty percent achieved sustained DMARD-free remission. Overall, high MBDA scores were associated with achieving DMARD-free remission (high vs. low HR 3.8, 95% CI 1.2–12.2). Among ACPA-negative RA patients, moderate or high scores associated strongly with DMARD-free remission (moderate vs. low HR 9.4, 95% CI 1.2–72.9; high vs. low HR 9.7, 95% CI 1.3–71.1). This association was independent of age and other clinical factors (high vs. low HR 8.2, 95% CI 1.1–61.8). For ACPA-negative RA patients, the biomarkers C-reactive protein, serum amyloid A and matrix metalloproteinase-3 were individually associated with sustained DMARD-free remission. Among ACPA-positive RA patients, scores were not associated with DMARD-free remission. Conclusions ACPA-negative RA patients who achieved sustained DMARD-free remission after treatment withdrawal were characterized by moderate to high MBDA scores at diagnosis. This is the first evidence that ACPA-negative RA can be subdivided in clinically relevant subsets at disease onset using a protein profile. Electronic supplementary material The online version of this article (10.1186/s13075-019-1902-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Debbie M Boeters
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands.
| | - Leonie E Burgers
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Eric H Sasso
- Crescendo Bioscience, South San Francisco, CA, USA
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, the Netherlands.,Department of Rheumatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
36
|
Luís M, Freitas J, Costa F, Buttgereit F, Boers M, Jap DS, Santiago T. An updated review of glucocorticoid-related adverse events in patients with rheumatoid arthritis. Expert Opin Drug Saf 2019; 18:581-590. [PMID: 31056959 DOI: 10.1080/14740338.2019.1615052] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Glucocorticoids represent a cornerstone in the treatment of rheumatoid arthritis. Their effect as a disease-modifying treatment in rheumatoid arthritis is well established. Despite this, the risk of adverse events of glucocorticoids, especially in high doses and over a long time, is constantly highlighted. Data on the prevalence and impact of glucocorticoid-related adverse effects in rheumatoid arthritis is needed, therefore, to be regularly revisited. AREAS COVERED In this review, our primary aim was to provide an update of evidence from randomized controlled trials and observational cohort studies on the safety of glucocorticoid treatment in rheumatoid arthritis. Our secondary aim was to provide a critical overview of the concerns raised with both study designs - randomized clinical trials versus nonrandomized observational studies - regarding the assessment of the safety of glucocorticoids in rheumatoid arthritis. EXPERT OPINION In the meantime, adherence to recommendations and consensus on standardized methodologies for monitoring and reporting adverse events is essential to improve our knowledge and competence in the best management of glucocorticoids.
Collapse
Affiliation(s)
- Mariana Luís
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - João Freitas
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - Flávio Costa
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal
| | - Frank Buttgereit
- b Department of Rheumatology and Clinical Immunology , Charité University Medicine , Berlin , Germany
| | - Maarten Boers
- c Department of Epidemiology and Biostatistics, Amsterdam Rheumatology and Immunology Center , Amsterdam University Medical Centers, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands
| | - Da Silva Jap
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,d Faculty of Medicine , University of Coimbra , Coimbra , Portugal.,e Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| | - Tânia Santiago
- a Rheumatology Department , Centro Hospitalar e Universitário de Coimbra , Coimbra , Portugal.,d Faculty of Medicine , University of Coimbra , Coimbra , Portugal
| |
Collapse
|
37
|
Malochet-Guinamand S, Lambert C, Gossec L, Soubrier M, Dougados M. Evaluation of the Implementation of Guidelines on the Treatment of Osteoporosis in Patients with Rheumatoid Arthritis. J Rheumatol 2019; 47:6-14. [PMID: 30877214 DOI: 10.3899/jrheum.180889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess whether the 2003 and 2014 French guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP) and the 2012 update of the French guidelines for the treatment of postmenopausal osteoporosis (PMOP) were applied in patients with rheumatoid arthritis (RA). METHODS We conducted a cross-sectional study of 776 patients with RA (19 centers). We collected the data required for the application of the various recommendations (age, sex, prednisone intake, low-energy fracture, history in the immediate family of hip fractures, and bone densitometry), anti-osteoporotic drugs, and the various factors that may be associated with the application of the recommendations. RESULTS Of the patients who should have received antiosteoporosis treatment, there were 22.6% actually treated (according to the 2014 guidelines), 27.3% actually treated according to the 2003 guidelines, and of postmenopausal women, 23.6% (according to the 2012 PMOP guidelines). Applying the 2014 GIOP guidelines increased the theoretical number of patients requiring treatment relative to the 2003 GIOP guidelines (77% vs 53%; p < 0.001). In multivariate analysis, being treated was associated with a spinal T score ≤ -2 SD according to the 2014 guidelines; with not taking part in physical activity for more than 30 min a day according to the 2003 guidelines; and with older age, lower body mass index, and a T score ≤ -2.5 SD in at least 1 site according to the PMOP guidelines. CONCLUSION Patients with RA had inadequate prevention of GIOP and PMOP. The management of osteoporosis needs to be improved in this population.
Collapse
Affiliation(s)
- Sandrine Malochet-Guinamand
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France. .,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité.
| | - Céline Lambert
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité
| | - Laure Gossec
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité
| | - Martin Soubrier
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité
| | - Maxime Dougados
- From the Rheumatology Department, and Biostatistics Unit (DRCI), University Hospital Clermont-Ferrand, Auvergne; Sorbonne University; Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University; Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité, Paris, France.,S. Malochet-Guinamand, MD, University Hospital Clermont-Ferrand, Rheumatology Department; C. Lambert, MSc, University Hospital Clermont-Ferrand, Biostatistics Unit (DRCI); L. Gossec, PhD, Sorbonne University, and Pitié Salpêtrière Hospital, AP-HP, Rheumatology Department; M. Soubrier, PhD, University Hospital Clermont-Ferrand, Rheumatology Department; M. Dougados, PhD, Rheumatology Department, Cochin Hospital, AP-HP, Paris Descartes University, and Clinical Epidemiology and Biostatistics, INSERM (U1153), PRES Sorbonne Paris-Cité
| |
Collapse
|
38
|
Daien C, Hua C, Gaujoux-Viala C, Cantagrel A, Dubremetz M, Dougados M, Fautrel B, Mariette X, Nayral N, Richez C, Saraux A, Thibaud G, Wendling D, Gossec L, Combe B. Update of French society for rheumatology recommendations for managing rheumatoid arthritis. Joint Bone Spine 2019; 86:135-150. [DOI: 10.1016/j.jbspin.2018.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2018] [Indexed: 02/07/2023]
|
39
|
Iudici M, Porcher R, Riveros C, Ravaud P. Time-dependent biases in observational studies of comparative effectiveness research in rheumatology. A methodological review. Ann Rheum Dis 2019; 78:562-569. [DOI: 10.1136/annrheumdis-2018-214544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/02/2019] [Accepted: 01/23/2019] [Indexed: 01/10/2023]
Abstract
ObjectiveTo assess to what extent time-dependent biases (ie, immortal time bias (ITB) and time-lag bias (TLB)) occur in the latest rheumatology observational studies, describe their main mechanisms and increase the awareness on this topic.MethodsWe searched PubMed for observational studies on rheumatic diseases published in leading medical journals in the last 5 years. Only studies with a time-to-event analysis exploring the association of one or more interventional strategies with an outcome were included. Each study was labelled as free from bias, at risk of TLB, at risk of misclassified ITB if the period of immortal time was incorrectly attributed to an intervention group, or at risk of excluded ITB if the immortal time was discarded from the analysis.ResultsWe included 78 papers. Most studies were performed in Europe or North America (46% each), were not industry funded (62%) and had a safety primary outcome (59%). In total, 13 (17%) studies were considered at risk of time-dependent biases. Among the studies at risk of ITB (n=8; 10%), in 5 (6%), waiting time to receive treatment was wrongly attributed to the treatment exposure group, which indicated misclassified ITB. Five (6%) studies were at risk of TLB: patients on conventional synthetic disease-modifying antirheumatic drugs (DMARD; first-line drugs) were compared with patients on biologic DMARDs (second or third-line drugs) without accounting for disease duration or prior medication use.ConclusionsOne in six comparative effectiveness observational studies published in leading rheumatology journals is potentially flawed by time-dependent biases.
Collapse
|
40
|
Klaassen Z, Wallis CJD, Fleshner NE. Abiraterone Acetate for Nonmetastatic Castration-Resistant Prostate Cancer—The Forgotten Dance Partner? JAMA Oncol 2019; 5:144-145. [DOI: 10.1001/jamaoncol.2018.5191] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Zachary Klaassen
- Division of Urology, Medical College of Georgia, Augusta University, Augusta
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Neil E. Fleshner
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
41
|
Effect of magnetic nanoparticles size on rheumatoid arthritis targeting and photothermal therapy. Colloids Surf B Biointerfaces 2018; 170:224-232. [DOI: 10.1016/j.colsurfb.2018.06.016] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/23/2018] [Accepted: 06/12/2018] [Indexed: 11/18/2022]
|
42
|
Palmowski Y, Buttgereit T, Buttgereit F. The 70th anniversary of glucocorticoids in rheumatic diseases: the second youth of an old friend. Rheumatology (Oxford) 2018; 58:580-587. [DOI: 10.1093/rheumatology/key169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/09/2018] [Indexed: 12/20/2022] Open
Abstract
Abstract
Seventy years ago, the first administration of cortisone in a patient with RA marked a milestone in the treatment of inflammatory diseases. However, the initial enthusiasm rapidly vanished as the administration of high doses for lengthy periods revealed worrisome adverse effects. It has taken several decades to overcome the (sometimes excessive) mistrust and to achieve a more differentiated evaluation of the benefit–risk profile and the adequate usage of glucocorticoids (GCs). Today, GCs remain indispensable for the treatment of many inflammatory conditions and their usefulness in RA as a disease-modifying low-dose co-medication is widely acknowledged. Recent studies show promising results concerning both traditional GCs and new formulations. Still, decades of relatively little scientific attention have resulted in a continuing lack of detailed evidence. Hence there is an ongoing need for further research regarding mechanisms of GC actions, the further optimization of treatment parameters for traditional GCs and new formulations.
Collapse
Affiliation(s)
- Yannick Palmowski
- Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
43
|
Giollo A, Bissell LA, Buch MH. Cardiovascular outcomes of patients with rheumatoid arthritis prescribed disease modifying anti-rheumatic drugs: a review. Expert Opin Drug Saf 2018; 17:697-708. [PMID: 29871535 DOI: 10.1080/14740338.2018.1483331] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Rheumatoid arthritis (RA) is associated with a heightened risk of cardiovascular disease (CVD), with both traditional CV risk factors and inflammation contributing to this risk. AREAS COVERED This review highlights the burden of CVD in RA and associated traditional CV risk factors, including the complexity of dyslipidemia in RA and the so-called 'lipid paradox.' Furthermore, the recognized RA-disease-specific factors associated with higher risk of CVD and the role of systemic inflammation in the pathogenesis of CVD in RA will be addressed. With the advent of biologic and targeted synthetic therapies in the treatment of RA, the effect of conventional and newer generation disease modifying anti-rheumatic therapies (DMARDs) on CV risk and associated risk factors will also be discussed. EXPERT OPINION Identifying the RA phenotype at greatest risk of CVD, understanding the interplay of increased traditional risk factors, common inflammatory processes and RA-specific factors, and personalized use of DMARDs according to disease phenotype and comorbidity to reduce this risk are key areas for future research.
Collapse
Affiliation(s)
- Alessandro Giollo
- a Leeds Institute of Rheumatic and Musculoskeletal Medicine , University of Leeds, Chapel Allerton Hospital , Leeds , UK.,b NIHR Leeds Biomedical Research Centre , Leeds Teaching Hospitals NHS Trust , Leeds , LS7 4SA , UK.,c Department of Medicine, Rheumatology Unit , University of Verona , Verona , Italy
| | - Lesley-Anne Bissell
- a Leeds Institute of Rheumatic and Musculoskeletal Medicine , University of Leeds, Chapel Allerton Hospital , Leeds , UK.,b NIHR Leeds Biomedical Research Centre , Leeds Teaching Hospitals NHS Trust , Leeds , LS7 4SA , UK
| | - Maya H Buch
- a Leeds Institute of Rheumatic and Musculoskeletal Medicine , University of Leeds, Chapel Allerton Hospital , Leeds , UK.,b NIHR Leeds Biomedical Research Centre , Leeds Teaching Hospitals NHS Trust , Leeds , LS7 4SA , UK
| |
Collapse
|
44
|
Jin S, Hsieh E, Peng L, Yu C, Wang Y, Wu C, Wang Q, Li M, Zeng X. Incidence of fractures among patients with rheumatoid arthritis: a systematic review and meta-analysis. Osteoporos Int 2018; 29:1263-1275. [PMID: 29546507 DOI: 10.1007/s00198-018-4473-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/01/2018] [Indexed: 12/17/2022]
Abstract
UNLABELLED This study is the first meta-analysis investigating the pooled incidence rates of fractures among patients with RA. Our results demonstrated that this population is at high risk of overall and fragility fractures. Consideration of vertebral imaging and RA-specific risk factor assessment may aid in fracture prevention for this vulnerable group. INTRODUCTION This systematic review and meta-analysis aims to estimate the incidence of fractures (overall and fragility) in patients with rheumatoid arthritis (RA). METHODS MEDLINE, EMBASE, and CENTRAL were searched for cohort studies reporting incidence of fractures among patients with RA. Two reviewers independently assessed all studies for inclusion and extracted data. Pooled analyses of incidence rates and relative risk of fractures were conducted using a random-effects model. Subgroup analyses investigated potential sources of heterogeneity, and predictors of fractures were summarized. RESULTS Twenty-five studies were included in total. The pooled incidence rates of overall and fragility fractures were 33.00 (95% CI 18.39-59.21) and 15.31 (95% CI 10.43-22.47) per 1000 person-years, respectively. Patients with RA had a higher risk of overall (RR 1.52, 95% CI 1.07-2.14) and fragility (RR 1.61, 95% CI 1.44-1.79) fractures. Subgroup analyses suggested a higher risk of fragility fractures among female patients (31.03 vs. 23.75 per 1000 person-years). The pooled site-specific incidence rates of vertebral, hip, forearm, and proximal humeral fractures were 7.51 (95% CI 3.27-17.23), 4.33 (95% CI 2.26-8.27), 3.40 (95% CI 2.27-5.10), and 1.86 (95% CI 1.36-2.53) per 1000 person-years, respectively. Clinical vertebral fractures were underestimated compared with radiographic screening (4.29 vs. 42.40 per 1000 person-years). Predictors of fractures included both traditional OP risk factors and RA-specific factors. CONCLUSIONS Patients with RA are at high risk of incident overall and fragility fractures. Consideration of vertebral imaging for patients with additional OP risk factors, including RA-specific risk factors, may help with early OP diagnosis and timely intervention.
Collapse
Affiliation(s)
- S Jin
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave, Beijing, 100730, China
| | - E Hsieh
- Section of Rheumatology, Yale School of Medicine, 300 Cedar Street, TAC S-525, P.O. Box 208031, New Haven, CT, 06520-8031, USA.
| | - L Peng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave, Beijing, 100730, China
| | - C Yu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave, Beijing, 100730, China
| | - Y Wang
- Department of Epidemiology and Bio-statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, School of Basic Medicine, Peking Union Medical College, Beijing, China
| | - C Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave, Beijing, 100730, China
| | - Q Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave, Beijing, 100730, China
| | - M Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave, Beijing, 100730, China.
| | - X Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, No.1 Shuaifuyuan, Wangfujing Ave, Beijing, 100730, China
| |
Collapse
|
45
|
Nikas SN. Long-term treatment with low dose glucocorticoids in Rheumatoid Arthritis: New tricks of an old drug. Mediterr J Rheumatol 2018; 29:13-16. [PMID: 32185291 PMCID: PMC7045951 DOI: 10.31138/mjr.29.1.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/28/2018] [Accepted: 03/10/2018] [Indexed: 12/17/2022] Open
Abstract
Glucocorticoids (GC) have been used for more than 70 years in the management of rheumatoid arthritis (RA). The immediate improvement of the clinical picture is one of their main advantages. However, RA is a chronic disease and unfortunately, long-term GC administration is associated with several serious adverse events. This is the major reason why GC therapy should be administered for the shortest possible period of time, with tapering as far as it is feasible. Although this is accepted as a “dogma”, there is recently growing evidence suggesting that low doses, even in the long-term, might not be as dangerous as previously believed. On the contrary, GC may be beneficial for RA patients in several ways, considering their protective role in radiographic progression or lymphoma development.
Collapse
|
46
|
Boeters DM, Nieuwenhuis WP, van Steenbergen HW, Reijnierse M, Landewé RBM, van der Helm-van Mil AHM. Are MRI-detected erosions specific for RA? A large explorative cross-sectional study. Ann Rheum Dis 2018; 77:861-868. [PMID: 29490980 DOI: 10.1136/annrheumdis-2017-212252] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 01/30/2018] [Accepted: 02/08/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVES MRI is recommended in the diagnostic process of rheumatoid arthritis (RA) to detect joint damage early. MRI-detected erosions are also present in symptom-free controls, especially at older age. It is unclear if RA-specific MRI-detected erosions can be distinguished from 'physiological' erosions in symptom-free individuals. This study compared MRI-detected erosions of patients with RA with healthy controls and with other arthritides. METHODS 589 newly presenting patients with early arthritis (238 RA, 351 other arthritides) and 193 symptom-free controls underwent contrast-enhanced 1.5T MRI of unilateral metacarpophalangeal and metatarsophalangeal (MTP) joints. Total erosion score (according to the Rheumatoid Arthritis MRI Scoring System), number, severity, location of erosions and simultaneous presence of MRI-detected inflammation (synovitis and/or bone marrow oedema) were compared; participants were categorised in three age groups (<40, 40-59, ≥60). RESULTS Patients with RA had statistically significant higher total erosion scores than controls but scores of individual persons largely overlapped. Grade ≥2 erosions and MTP5 erosions were specific for RA (specificity 98%-100% and 90%-98% for different age groups). MTP1 erosions were only specific if aged <40 (specificity 98%) and erosions with inflammation if aged <60 (specificity 91%-100%). ≥1 of the mentioned erosion characteristics were present in 29% of patients with RA. Comparing patients with RA with other arthritides revealed that grade ≥2 erosions and MTP5 erosions remained specific for RA (specificity ≥89%) as well as MTP1 erosions if aged <40 (specificity 93%), in contrast to erosions combined with inflammation (specificity 49%-85%). CONCLUSIONS Total erosion scores of individual persons were largely overlapping. Erosion characteristics specific for RA were identified, but were infrequently present. Caution is needed not to overestimate the value of MRI erosions in the diagnostic process.
Collapse
Affiliation(s)
- Debbie M Boeters
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter P Nieuwenhuis
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert B M Landewé
- Department of Clinical Rheumatology and Immunology, Amsterdam Medical Center Amsterdam and Atrium Medical Center Heerlen, Heerlen, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
47
|
Buttgereit F, Bijlsma JW, Strehl C. Will we ever have better glucocorticoids? Clin Immunol 2018; 186:64-66. [DOI: 10.1016/j.clim.2017.07.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 07/26/2017] [Indexed: 12/20/2022]
|
48
|
Bartoloni E, Alunno A, Valentini V, Luccioli F, Valentini E, La Paglia G, Bistoni O, Gerli R. Role of Inflammatory Diseases in Hypertension. High Blood Press Cardiovasc Prev 2017; 24:353-361. [PMID: 28597352 DOI: 10.1007/s40292-017-0214-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 05/30/2017] [Indexed: 12/24/2022] Open
Abstract
Chronic inflammatory diseases (CID) are characterized by an increased risk of cardiovascular (CV) morbidity and mortality. Several mechanisms, including early acceleration of subclinical atherosclerotic damage, inflammatory markers and immune system deregulation factors, have been demonstrated to strictly interplay for development and progression of atherosclerosis. Moreover, traditional CV risk factors are likely to explain at least some of the excess of CV risk in these patients. Among traditional CV risk factors, compelling evidence suggests a higher incidence and prevalence of hypertension in patients with CID in comparison to the general population. Moreover, hypertension represents an important predictor of CV events in these patients. Pathogenic mechanisms underlying the rise of blood pressure in CID are multifactorial and still poorly investigated. Indeed, multiple disease-related factors may affect blood pressure control in these patients and hypertension may affect disease prognosis and increase CV risk. Better knowledge of the complex interplay between hypertension and CID will be important to elucidate pathogenic mechanisms and to improve CV outcome in these patients. Aim of this review is to highlight available evidence on the relationship between hypertension and CID and to elucidate the multiple factors that may affect blood pressure control in these disorders.
Collapse
Affiliation(s)
- E Bartoloni
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - A Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - V Valentini
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - F Luccioli
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - E Valentini
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - G La Paglia
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - O Bistoni
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - Roberto Gerli
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy.
| |
Collapse
|
49
|
Buttgereit F, Bijlsma JW. Glucocorticoids in rheumatoid arthritis: the picture is shaping up. Ann Rheum Dis 2017; 76:1785-1787. [DOI: 10.1136/annrheumdis-2017-211187] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 03/29/2017] [Accepted: 04/05/2017] [Indexed: 02/04/2023]
|