1
|
Goto Y, Nagafuchi H, Kaga Y, Kawahata K. Association between glucocorticoid discontinuation and incidence of infection in older adults with rheumatoid arthritis: A retrospective cohort study. Int J Rheum Dis 2023; 26:1987-1995. [PMID: 37504066 DOI: 10.1111/1756-185x.14851] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/24/2023] [Accepted: 07/16/2023] [Indexed: 07/29/2023]
Abstract
AIM Old age and glucocorticoid (GC) use increase the susceptibility to infection in patients with rheumatoid arthritis (RA). Accordingly, we investigated whether GC discontinuation reduces the incidence of infection in older adults with RA and analyzed factors associated with GC discontinuation. METHODS Medical records of patients with RA aged ≥60 years were retrieved, and the association between GC use and the incidence of infection was investigated. The participants were divided into three groups: GC-continued, GC-discontinued, and non-GC; the incidence of infection was statistically analyzed. Furthermore, patient treatments and comorbidities were examined. RESULTS Among 389 patients with RA included in the study (n = 122, n = 126, and n = 141 in the GC-discontinued, GC-continued, and non-GC groups, respectively), 65 (16.7%) patients developed infection, and the incidence of infection was significantly higher in the GC-continued group than in the GC-discontinued (p = .021) and non-GC (p = .0003) groups; there was no significant difference between the non-GC and GC-discontinued groups (p = .659). The GC-discontinued group was more likely to require biologic use throughout the disease course than the other two groups. Comorbidities, especially malignancies (p = .004), were more common in the GC-continued group than in the GC-discontinued group (p = .007). CONCLUSION In patients with RA aged ≥60 years receiving GCs, GC discontinuation reduced the incidence of infection. Therefore, a further analysis of factors that help reduce GC use is necessary.
Collapse
Affiliation(s)
- Yutaka Goto
- Division of Rheumatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hiroko Nagafuchi
- Division of Rheumatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yasuyuki Kaga
- Department of Practical Management of Medical Information, St. Marianna University School of Medicine, Kawasaki, Japan
- EPS Corporation, Tokyo, Japan
| | - Kimito Kawahata
- Division of Rheumatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| |
Collapse
|
2
|
Almayali AAH, Boers M, Hartman L, Opris D, Bos R, Kok MR, Da Silva JA, Griep E, Klaasen R, Allaart CF, Baudoin P, Raterman HG, Szekanecz Z, Buttgereit F, Masaryk P, Lems W, Smulders Y, Cutolo M, Ter Wee MM. Three-month tapering and discontinuation of long- term, low-dose glucocorticoids in senior patients with rheumatoid arthritis is feasible and safe: placebo-controlled double blind tapering after the GLORIA trial. Ann Rheum Dis 2023; 82:1307-1314. [PMID: 37541762 DOI: 10.1136/ard-2023-223977] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/22/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE The randomised placebo-controlled GLORIA (Glucocorticoid LOw-dose in RheumatoId Arthritis) trial evaluated the benefits and harms of prednisolone 5 mg/day added to standard care for 2 years in patients aged 65+ years with rheumatoid arthritis (RA). Here, we studied disease activity, flares and possible adrenal insufficiency after blinded withdrawal of study medication. METHODS Per protocol, patients successfully completing the 2-year trial period linearly tapered and stopped blinded study medication in 3 months. We compared changes in disease activity after taper between treatment groups (one-sided testing). Secondary outcomes (two-sided tests) comprised disease flares (DAS28 (Disease Activity Score 28 joints) increase >0.6, open-label glucocorticoids or disease-modifying antirheumatic drug (DMARD) increase/switch after week 4 of tapering) and symptoms/signs of adrenal insufficiency. In a subset of patients from 3 Dutch centres, cortisol and ACTH were measured in spot serum samples after tapering. RESULTS 191 patients were eligible; 36 met treatment-related flare criteria and were only included in the flare analysis. Mean (SD) DAS28 change at follow-up: 0.2 (1.0) in the prednisolone group (n=76) vs 0.0 (1.2) in placebo (n=79). Adjusted for baseline, the between-group difference in DAS28 increase was 0.16 (95% confidence limit -0.06, p=0.12). Flares occurred in 45% of prednisolone patients compared with 33% in placebo, relative risk (RR) 1.37 (95% CI 0.95 to 1.98; p=0.12). We found no evidence for adrenal insufficiency. CONCLUSIONS Tapering prednisolone moderately increases disease activity to the levels of the placebo group (mean still at low disease activity levels) and numerically increases the risk of flare without evidence for adrenal insufficiency. This suggests that withdrawal of low-dose prednisolone is feasible and safe after 2 years of administration.
Collapse
Affiliation(s)
| | - Maarten Boers
- Department of Epidemiology & Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Linda Hartman
- Department of Epidemiology & Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Daniela Opris
- Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Reinhard Bos
- Department of Rheumatology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Marc R Kok
- Department of Rheumatology and Clinical Immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Jose Ap Da Silva
- Rheumatology Department, University of Coimbra Faculty of Medicine, Coimbra, Portugal
| | - Ed Griep
- Department of Rheumatology, Antonius Hospital, Sneek, The Netherlands
| | - Ruth Klaasen
- Department of Rheumatology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Cornelia F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul Baudoin
- Rheumatology, Reumazorg Flevoland, Emmeloord, The Netherlands
| | - Hennie G Raterman
- Department of Rheumatology, Northwest Clinics, Alkmaar, The Netherlands
| | - Zoltan Szekanecz
- Department of Rheumatology, University of Debrecen, Debrecen, Hungary
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charite University Hospital Berlin, Berlin, Germany
| | - Pavol Masaryk
- Rheumatology, National Institute of Rheumatic Diseases, Piestany, Slovakia
| | - Willem Lems
- Amsterdam Rheumatology and Immunology Center, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Yvo Smulders
- Department of Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Maurizio Cutolo
- Department of Internal Medicine, Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Genova, Italy
| | - Marieke M Ter Wee
- Department of Epidemiology & Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| |
Collapse
|
3
|
Lee J, Singh N, Gray SL, Makris UE. Optimizing Medication Use in Older Adults With Rheumatic Musculoskeletal Diseases: Deprescribing as an Approach When Less May Be More. ACR Open Rheumatol 2022; 4:1031-1041. [PMID: 36278868 PMCID: PMC9746667 DOI: 10.1002/acr2.11503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 09/01/2022] [Accepted: 09/04/2022] [Indexed: 12/15/2022] Open
Abstract
The world population is aging, and the rheumatology workforce must be prepared to care for medically complex older adults. We can learn from our colleagues and experts in geriatrics about how to best manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older adults in the context of delivering care for rheumatic and musculoskeletal diseases (RMDs). Polypharmacy, a common occurrence in an aging population with multimorbidity, affects half of older adults with RMDs and is associated with increased risk of morbidity and mortality. In addition, potentially inappropriate medications that should be avoided under most circumstances is common in the RMD population. In recent years, deprescribing, known as the process of tapering, stopping, discontinuing, or withdrawing drugs, has been introduced as an approach to improve appropriate medication use among older adults and the outcomes that are important to them. As the rheumatology patient population ages globally, it is imperative to understand the burden of polypharmacy and the potential of deprescribing to improve medication use in older adults with RMDs. We encourage the rheumatology community to implement geriatric principles, when possible, as we move toward becoming an age-friendly health care specialty.
Collapse
Affiliation(s)
- Jiha Lee
- JUniversity of MichiganAnn Arbor
| | | | | | - Una E. Makris
- University of Texas Southwestern Medical Center and VA North Texas Health Care SystemDallas
| |
Collapse
|
4
|
How to taper glucocorticoids in inflammatory rheumatic diseases? A narrative review of novel evidence in rheumatoid arthritis, systemic lupus erythematosus, and giant cell arteritis. Joint Bone Spine 2021; 89:105285. [PMID: 34601110 DOI: 10.1016/j.jbspin.2021.105285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/22/2021] [Indexed: 01/24/2023]
Abstract
Glucocorticoids (GCs) remain regularly used drugs in patients with chronic inflammatory rheumatic diseases. As long-term intake at high dosages is associated with harm, it is generally advised that GCs be tapered and stopped. However, most recommendations concerning tapering have been eminence- or consensus-based. In this narrative review, we present novel data from recent studies (SEMIRA, CORTICOLUP, and GiACTA) shedding light from different angles on the effects of tapering GCs in patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and giant cell arteritis (GCA). In RA and SLE, our main findings comprise that (a) the majority of RA and SLE patients can successfully taper their GC, but that (b) tapering increases the risk of flare. In GCA, tocilizumab was shown to be a potent GC-sparing agent. Finally, we also present exemplary tapering schemes for RA, SLE, and GCA, although different tapering regimens have not yet been sufficiently compared in randomized trials.
Collapse
|
5
|
Maassen JM, van Ouwerkerk L, Allaart CF. Tapering of disease-modifying antirheumatic drugs: an overview for daily practice. THE LANCET. RHEUMATOLOGY 2021; 3:e659-e670. [PMID: 38287612 DOI: 10.1016/s2665-9913(21)00224-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/25/2021] [Accepted: 07/08/2021] [Indexed: 01/31/2024]
Abstract
In this Review, we discuss the possibility of drug tapering in patients with rheumatoid arthritis in remission or low disease activity, for glucocorticoids and disease-modifying antirheumatic drugs. We review international guidelines and recommendations, as well as remaining uncertainties, and provide an overview of the current literature. Three strategies of tapering are discussed: (1) tapering by discontinuation of one of the drugs in combination therapy regimens, (2) tapering by reducing the dose of one of the drugs in combination therapy regimens, and (3) tapering by dose reduction of monotherapy with disease-modifying antirheumatic drugs. We discuss the outcomes and robustness of evidence of trials and observational cohorts, and we give a trajectory for further research and drug tapering in daily practice.
Collapse
Affiliation(s)
| | - Lotte van Ouwerkerk
- Department of Rheumatology, Leiden University Medical Center, Leiden, Netherlands
| | | |
Collapse
|
6
|
McWilliams DF, Thankaraj D, Jones-Diette J, Morgan R, Ifesemen OS, Shenker NG, Walsh DA. The efficacy of systemic glucocorticosteroids for pain in rheumatoid arthritis: a systematic literature review and meta-analysis. Rheumatology (Oxford) 2021; 61:76-89. [PMID: 34213524 PMCID: PMC8742830 DOI: 10.1093/rheumatology/keab503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Objectives Glucocorticosteroids (GCs) are recommended to suppress inflammation in people with active RA. This systematic review and meta-analysis aimed to quantify the effects of systemic GCs on RA pain. Methods A systematic literature review of randomized controlled trials (RCTs) in RA comparing systemic GCs to inactive treatment. Three databases were and spontaneous pain and evoked pain outcomes were extracted. Standardized mean differences (SMDs) and mean differences were meta-analysed. Heterogeneity (I2, tau statistics) and bias (funnel plot, Egger’s test) were assessed. Subgroup analyses investigated sources of variation. This study was pre-registered (PROSPERO CRD42019111562). Results A total of 18 903 titles, 880 abstracts and 226 full texts were assessed. Thirty-three RCTs suitable for the meta-analysis included 3123 participants. Pain scores (spontaneous pain) decreased in participants treated with oral GCs; SMD = −0.65 (15 studies, 95% CI −0.82, −0.49, P <0.001) with significant heterogeneity (I2 = 56%, P =0.0002). Efficacy displayed time-related decreases after GC initiation. Mean difference visual analogue scale pain was −15 mm (95% CI −20, −9) greater improvement in GC than control at ≤3 months, −8 mm (95% CI −12, −3) at >3–6 months and −7 mm (95% CI −13, 0) at >6 months. Similar findings were obtained when evoked pain outcomes were examined. Data from five RCTs suggested improvement also in fatigue during GC treatment. Conclusion Oral GCs are analgesic in RA. The benefit is greatest shortly after initiation and GCs might not achieve clinically important pain relief beyond 3 months. Treatments other than anti-inflammatory GCs should be considered to reduce the long-term burden of pain in RA.
Collapse
Affiliation(s)
- Daniel F McWilliams
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Divya Thankaraj
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Julie Jones-Diette
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | | | - Onosi S Ifesemen
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | | | - David A Walsh
- Division of ROD, Pain Centre Versus Arthritis, NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| |
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW Glucocorticoids and opioids are longstanding, common treatments for rheumatoid arthritis (RA) symptoms. High-quality clinical trials have established that glucocorticoids improve outcomes in RA, but debate continues as to whether their benefits outweigh their risks. We reviewed recent studies on patterns of glucocorticoid and opioid prescribing in RA, and associated harms. RECENT FINDINGS At present, a large proportion of RA patients remain on glucocorticoids and/or opioids long-term. Likelihood and risk of both glucocorticoid and opioid exposure vary across the population, and are influenced by provider factors. Opioids are also associated with delays in disease-modifying treatment initiation. Recent evidence increasingly demonstrates toxicity associated with even low-dose glucocorticoids (≤7.5 mg/day). Up to two-thirds of RA patients may be able to discontinue chronic low-dose glucocorticoids without flare or adrenal insufficiency. These new data have led to changes in clinical practice guidelines for glucocorticoid use in RA. SUMMARY Although low-dose and short-term glucocorticoid use is extremely common and effective in RA management, increasing evidence of toxicity has led experts to begin recommending that such exposure be minimized. Despite a lack of data to suggest opioids improve RA disease activity, they are used commonly, continued long-term, and associated with delayed effective therapy.
Collapse
Affiliation(s)
| | - Beth I Wallace
- University of Michigan Medical School
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| |
Collapse
|
8
|
Affiliation(s)
- Elizabeth R Volkmann
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA.
| |
Collapse
|