Dose and duration are associated with an increased risk for incident cardiovascular events in steroid-naïve patients
INTRODUCTION
Rheumatoid arthritis is a chronic inflammatory disease that affects a person’s joints, and may cause pain and disability. Rheumatoid arthritis can affect people of all ages, but it most often starts between the ages of 30 and 50 – although this can depend on where you live. Rheumatoid arthritis is more common in women than men. People with rheumatoid arthritis have an increased risk of suffering from cardiovascular diseases such as heart attacks, heart failure or stroke. This is because the inflammation involved in rheumatoid arthritis can have an effect on other systems in the body, as well as the joints. Some medicines used to treat rheumatoid arthritis can also increase the risk of cardiovascular disease.
Glucocorticoids are a type of steroid medicine used to treat rheumatoid arthritis and other inflammatory conditions. Although most doctors are aware of the risk of using high doses of these medicines, many think that low doses are safe. However, one long-term risk of using glucocorticoids is an increase in cardiovascular events.
There is not much information about the risks of low-dose or relatively short-term use of these medicines.
WHAT DID THE AUTHORS HOPE TO FIND?
The authors wanted to find out the safety and risk of using relatively low doses of glucocorticoids for short periods. Since people with rheumatoid arthritis already have an increased risk of cardiovascular disease, they wondered what effect this would have in terms of new cardiovascular events.
WHO WAS STUDIED?
The study looked at over 19,000 people with rheumatoid arthritis who had not taken glucocorticoids before.
Everyone was over the age of 18 and living in the United States.
HOW WAS THE STUDY CONDUCTED?
This was a retrospective observational study, which means that the authors used an existing database of patient records to look back and find people for the study. There was no interventional treatment given. The database used was from the CorEvitas registry, which regularly collects information from people with rheumatoid arthritis and their doctors. People were included in this study if they started taking a glucocorticoid for the first time after they enrolled in the CorEvitas registry. The authors used this information to compare the risk of new cardiovascular events in people who started glucocorticoids to those who did not. The results were analysed based on the dose and duration of use.
WHAT WERE THE MAIN FINDINGS OF THE STUDY?
The main finding was that daily glucocorticoid doses of less than 5 mg of prednisone-equivalent were not associated with an increased risk, but all higher daily doses were. The risk increased directly with dose, with the greatest estimated risks for people taking 5–9 mg or more than 10 mg per day.
As well as the daily dose, the authors looked at cumulative use over the past 6 months for each person. They found there was a dose threshold that was associated with an increased risk of cardiovascular events over time. However, there was no increased risk if people took less than 750 mg over 6 months, or less than 1100 mg over 1 year.
The authors also found a threshold for how long these medicines should be used for. The results showed
no increased risk in people who used glucocorticoids for up to 80 days over the preceding 6 months, or up to 100 days over 1 year. There was no increased risk for cardiovascular events in people taking glucocorticoid medicines for fewer days.
ARE THESE FINDINGS NEW?
Yes. This is the first time these thresholds have been described for people with rheumatoid arthritis taking glucocorticoid medicines.
WHAT ARE THE LIMITATIONS OF THE STUDY?
One limitation is that the study used retrospective information from an existing database study. People taking part in these kinds of observational registries are treated without being assigned to a specific intervention. The authors took into account other factors that might have affected the results, but there is still a risk of possible bias, or that other external factors might have had an impact.
WHAT DO THE AUTHORS PLAN ON DOING WITH THIS INFORMATION?
The authors hope this information will enhance education for doctors and their patients on the risks of low-dose, short-term glucocorticoids. Additional studies are needed to see if the risk is the same in other diseases that are treated with these medicines.
WHAT DOES THIS MEAN FOR ME?
If you have rheumatoid arthritis, you should be aware of the risk of cardiovascular events even with relatively short-term use of steroid medicines. Your doctor should try to taper (reduce) the amount of medicine you take to the lowest possible dose that still controls your rheumatoid arthritis.
It is important that you do not change the dose of your medicine yourself. If you have any concerns about your disease or its treatment, you should talk to your doctor.
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Date prepared: November 2021
Summary based on research article published on: 2 July 2021
From: Ocon AJ, et al. Short-term dose and duration-dependent glucocorticoid risk for cardiovascular events in glucocorticoid-naïve patients with rheumatoid arthritis. Ann Rheum Dis 2021;80:1522–29. doi:10.1136/annrheumdis-2021-220577
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