Low-dose glucocorticoids are safe to use in early rheumatoid arthritis

This 7-year analysis supports the good safety profile of low-dose glucocorticoids for early active rheumatoid arthritis

Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints, causing pain and disability. It can also affect internal organs. Rheumatoid arthritis is more common in older people, but there is also a high prevalence in young adults, adolescents and even children, and it affects women more frequently than men. Many people with rheumatoid arthritis are given a medicine called a glucocorticoid (often shortened to just steroid), especially in the early stages of the disease. Although glucocorticoids can help to relieve symptoms, and may help with some of the underlying inflammation, they can have side effects. Because of this, it is recommended that people are prescribed the lowest possible dose for the shortest possible time.

What did the authors hope to find?
The authors wanted to find out if there were side effects from long-term use of glucocorticoids in people with early rheumatoid arthritis in a real-life setting.

Who was studied?
The study looked at 602 patients (476 women) from the early arthritis Etude et Suivi des POlyarthrites Indifférenciées Récentes (ESPOIR) cohort. Everyone included was aged between 18 to 70 years and had been diagnosed with early arthritis, which means they had experienced the signs and symptoms of the disease for less than 6 months.

How was the study conducted?
ESPOIR is a French prospective multicentre observational study sponsored by the French Society of Rheumatology. This type of study means that patients are enrolled and medical information is recorded at regular intervals in a database, but there is no particular intervention or drug being investigated. Everyone was classified into one of two groups depending on whether or not they had received glucocorticoids at least once over the 7 years of the study. The authors then looked to see if there was a difference between these
groups in deaths, severe infections, bone fractures, and cardiovascular diseases such as heart failure.

What were the main findings of the study?
Overall, about two-thirds of people received glucocorticoids. Glucocorticoids were mostly given at very low doses (5 mg per day or less). Over half of people started taking glucocorticoids during the first 6 months of their disease. People taking glucocorticoids had more active disease, disability and higher levels of biomarkers in their blood than people not taking glucocorticoids. These biomarkers are a way of measuring inflammation, for example by looking for certain proteins, which means that people taking glucocorticoids had more severe disease and more underlying inflammation. Compared with people not taking glucocorticoids, those receiving these drugs also used more of other types of medicines, including non-steroidal anti-infiammatory drugs (often
shortened to NSAIDs), synthetic and biological disease-modifying antirheumatic drugs. Overall, in 602 people over 7 years there were 65 events that the investigators were looking for – which included 7 deaths, 14 cardiovascular diseases, 19 severe infections and 25 fractures. Of these, 44 (11.4%) occurred in patients taking glucocorticoids, and 21 (9.7%) occurred in people who had never taken glucocorticoids. This finding shows that there was no significant difference between the two groups in terms of major
safety events. Although the findings need further confirmation, they strongly support the current recommendations that glucocorticoids should be used for early rheumatoid arthritis for the shortest period and at the lowest possible dose.

Are these findings new?
To the authors’ knowledge, this is the first cohort study specifically designed to assess glucocorticoid side effects in people with early rheumatoid arthritis.

What are the limitations of the study?
This was an observational study, which means that it relies on information being collected accurately. The events and comorbid diseases studied were reported by the patients, so it is possible that some may have been missed or forgotten. Additionally, almost everyone who received glucocorticoids was prescribed a low dose, it was not possible to see how side effects may differ with different dose levels. There may also be other factors that have not been studied.

What do the authors plan on doing with this information?
The authors are planning to repeat the analysis in the same group after 10 years.

What does this mean for me?
If you have early rheumatoid arthritis, you may be prescribed glucocorticoids, which may help to relieve the signs and symptoms. If your disease activity is more severe, or if you have certain biomarkers in your blood, your doctor might combine glucocorticoids with other types of medicines. Although there have been some concerns about using glucocorticoids, this study supports the good safety profile of low-dose glucocorticoid therapy in early active rheumatoid arthritis. If you have concerns about your medicine, it is very important that you do not stop taking it without talking to your doctor first.

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Date prepared: November 2017

Summary based on research article published on: 9 October 2017
From: Roubille, C. et al. Seven-year tolerability profile of glucocorticoids use in early rheumatoid arthritis: data from the ESPOIR cohort Ann Rheum Dis 2017;76:1797–1802. doi: 10.1136/annrheumdis-2016-210135

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