High steroid-free success rates after glucocorticoid bridging

90% of people with early rheumatoid arthritis are steroid-free 2 years after bridging therapy

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 40 and 60. Rheumatoid arthritis is more common in women than men. Glucocorticoids are a type of medicine used to treat rheumatoid arthritis. It has been shown that glucocorticoids such as prednisone can quickly stop inflammation and improve pain and function in people with rheumatoid arthritis. However, it is also known that the longer people take prednisone, the greater the risk that they may have side effects. Because of this, it is recommended to gradually reduce and stop these glucocorticoids as soon as possible, preferably within 3 months. Doctors refer to this as tapering. While the glucocorticoids are being reduced, slow-acting anti-rheumatic drugs are started, that can hopefully ‘take over’ from glucocorticoids after they are stopped. This is why it is called glucocorticoid bridging therapy. Unfortunately, there is a risk that the symptoms of inflammation will return when the glucocorticoids are stopped, and that the slow-acting drugs might not work as well.

The authors wanted to see what is already known about the chances of successfully stopping glucocorticoids after bridging therapy in people newly diagnosed with rheumatoid arthritis, and whether people who receive bridging therapy end up having to go back on glucocorticoids.

This study didn’t directly study a group of people. Instead it looked at published information from other studies. All the included studies were in people with early rheumatoid arthritis who had not yet tried methotrexate. Everyone started on glucocorticoids in their particular study.

This was a systematic literature review and meta-analysis. A systematic review aims to identify all the published evidence on a particular topic and draw it together into one summary. This paper also included a meta-analysis, which means the authors used statistics to check that the conclusions were meaningful, and not caused by chance. The authors reviewed the scientific literature for studies about people with rheumatoid arthritis who were newly diagnosed and had started their first treatment. This included clinical trials, but also observational reports
from normal daily practice. The people in the studies had experienced their first rheumatoid arthritis symptoms around 4–6 months before entering the studies. From an initial list of over 7,000 papers, they found 10 clinical trials with relevant information about glucocorticoid bridging therapy. The percentages of people still using glucocorticoids after bridging was used as
measure of unsuccessful discontinuation.

The main finding was that very few studies have looked at stopping glucocorticoids after they were used as bridging therapy. Only 4 of the 10 clinical trials reported detailed information about this. When the authors combined data from these four trials, they found that 22% of the people who started glucocorticoid bridging therapy were on glucocorticoids 12 months later – either because they had not been able to stop, or because they needed to restart. After 24 months this had reduced to 10%. This means that 90% of people with early rheumatoid arthritis were steroid-free 2 years after bridging therapy. The authors also noticed that all four studies used a fixed schedule to taper and stop glucocorticoids, which may help to let more patients stop. It may be that in daily practice such schedules are not used, but no data has been found to support this idea.

To the best of the authors’ knowledge, this is the first study combining data on glucocorticoid use after bridging therapy.

Studies on bridging therapy have focused on the benefits and risks during the use of glucocorticoids, but most have not reported on the success of stopping them after bridging. Because of this, it was not possible to include data from all 10 studies that were originally chosen. The authors would have liked to look in more detail – for instance on the effect of dose and duration of glucocorticoid bridging – but this was not possible due to the limited information.

The authors of this paper have contacted the researchers from the 10 studies identified, and asked them to share the original data they collected on individual patients. Overall, 7 researchers have agreed. This data will be pooled and used for a new analysis, which should answer the research question in much more detail.

If you have rheumatoid arthritis, you may be prescribed a glucocorticoid as part of your first treatment. Glucocorticoids can give very fast improvement in your symptoms, and in the short term this may outweigh the risk of side effects. This study shows that you will probably be able to reduce and stop the glucocorticoid within 1 year. It is very important that you do not try to stop or change any medicines yourself – always talk to your doctor first.

If you have any concerns about your disease or its treatment, you should talk to your doctor.

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Date prepared: June 2022
Summary based on research article published on: 25 April 2022
From: van Ouwerkerk L, et al. 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(7):937–43. doi:10.1136/annrheumdis-2022-222338

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