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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.
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Affiliation(s)
- Maarten Boers
- Department of Epidemiology and Data Science, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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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.
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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
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Santiago T, Voshaar M, de Wit M, Carvalho PD, Buttgereit F, Cutolo M, Paolino S, Castelar Pinheiro GR, Boers M, Da Silva JAP. Patients’ and rheumatologists’ perspectives on the efficacy and safety of low-dose glucocorticoids in rheumatoid arthritis—an international survey within the GLORIA study. Rheumatology (Oxford) 2021; 60:3334-3342. [DOI: 10.1093/rheumatology/keaa785] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 10/30/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Objective
To evaluate the current perspectives of patients and health professionals regarding the efficacy and safety of low-dose glucocorticoids (GCs) in RA.
Methods
Two online surveys were disseminated to patients and health professionals, in their native language, through national patient organizations and national rheumatology medical societies, respectively. SurveyMonkey®, MediGuard.org and the Glucocorticoid Low-dose Outcome in RA Study (GLORIA) website were used to offer and deliver these surveys.
Results
A total of 1221 RA patients with exposure to GCs, and 414 rheumatologists completed the surveys. Patients and rheumatologists reported high levels of agreement regarding the efficacy of low-dose GCs: at least 70% considered that they are very rapid and effective in the control of signs and symptoms of RA. However, half of the patients also reported having suffered serious adverse events with GCs, and 83% described concerns about safety. The majority of rheumatologists estimated that endocrine, ophthalmologic and cutaneous adverse events affect >4% of all patients treated with low-dose GCs for 2 years, based on a heat map.
Conclusions
RA patients with self-reported exposure to GCs express high levels of satisfaction with low-dose GCs efficacy, as do rheumatologists. However, both expressed excessive concerns regarding the safety of GCs (greatly exceeding the published evidence data), which may compromise the optimal use of this medication. This study indicates that there is an unmet need for appropriately designed prospective trials that shed light on the real risk associated with low-dose GCs, as well as a need for renovated educational programs on the real benefits and harms of low-dose GCs, for both patients and physicians.
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Affiliation(s)
- T Santiago
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (i.CBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - M Voshaar
- Department of Psychology, Health and Technology, Enschede, Netherlands and Stichting Tools Patient Empowerment, University of Twente, Amsterdam, Netherlands
| | - M de Wit
- Department of Medical Humanities, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - P D Carvalho
- Department of Rheumatology, Centro Hospitalar Universitário do Algarve, Faro, Portugal
- Lisbon Academic Medical Centre, Lisbon, Portugal
- Algarve Biomedical Center, Faro, Portugal
| | - F Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité University Medicine Berlin, Berlin, Germany
| | - M Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Polyclinic Hospital San Martino, Genova, Italy
| | - S Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Polyclinic Hospital San Martino, Genova, Italy
| | - G R Castelar Pinheiro
- Discipline of Rheumatology, Medical Science School, Rio de Janeiro State University, Rio de Janeiro, Brazil
| | - M Boers
- Department of Epidemiology and Biostatistics, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - J A P Da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (i.CBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Palmowski A, Buttgereit F. Reducing the Toxicity of Long-Term Glucocorticoid Treatment in Large Vessel Vasculitis. Curr Rheumatol Rep 2020; 22:85. [PMID: 33047263 PMCID: PMC7550368 DOI: 10.1007/s11926-020-00961-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 12/14/2022]
Abstract
Purpose While glucocorticoids (GCs) are effective in large vessel vasculitis (LVV), they may cause serious adverse events (AEs), especially if taken for longer durations and at higher doses. Unfortunately, patients suffering from LVV often need long-term treatment with GCs; therefore, toxicity needs to be expected and countered. Recent Findings GCs remain the mainstay of therapy for both giant cell arteritis and Takayasu arteritis. In order to minimize their toxicity, the following strategies should be considered: GC tapering, administration of conventional synthetic (e.g., methotrexate) or biologic (e.g., tocilizumab) GC-sparing agents, as well as monitoring, prophylaxis, and treatment of GC-related AEs. Several drugs are currently under investigation to expand the armamentarium for the treatment of LVV. Summary GC treatment in LVV is effective but associated with toxicity. Strategies to minimize this toxicity should be applied when treating patients suffering from LVV.
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Affiliation(s)
- Andriko Palmowski
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin, Berlin, Germany
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin, Berlin, Germany.
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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.
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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
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