Very low dose glucocorticoids do not appear to increase cardiovascular risk in people with rheumatoid arthritis
Introduction
Rheumatoid arthritis is a chronic inflammatory disease that mainly affects a person’s joints, causing pain and disability among other symptoms. Rheumatoid arthritis can affect people of all ages, but it most often starts between the ages of 40 and 60. It is more common in women than men.
There are many treatments available for rheumatoid arthritis, including glucocorticoids (often shortened to steroids). But having rheumatoid arthritis and using systemic glucocorticoids have each been linked with an increased risk of cardiovascular or heart disease. It is not known whether there is a ‘safe’ dose or duration of glucocorticoids that can be used for people with rheumatoid arthritis.
What did the authors hope to find?
The authors wanted to find out whether there is a safe dose or duration of glucocorticoids for people with rheumatoid arthritis. They aimed to look specifically at cardiovascular events.
Who was studied?
The study included 12,233 adults with rheumatoid arthritis. Most people taking part were Hong Kong Chinese, and had been diagnosed with rheumatoid arthritis between 2006 and 2015.
How was the study conducted?
This was a population-based, retrospective cohort study. This means the authors used existing databases of patient records. There was no interventional treatment given.
The authors used a city-wide medical database from Hong Kong to collect information about people’s risk factors and any cardiovascular events they may have suffered, and what medicines they were taking. They then used statistical modelling to analyse the links between glucocorticoid use and the occurrence of the first so-called major adverse cardiovascular event, or MACE. This is a term for a group of cardiovascular events: heart attack, unstable angina (chest pain), stroke, or death from a cardiovascular cause.
What were the main findings of the study?
The main finding was that over an average follow-up period of 8 years, 7% of people experienced a MACE event. People who were using prednisolone with a dose of 5 mg or more a day had around twice the risk of suffering a MACE event compared to those not using glucocorticoids. Additionally, there did not appear to be a safe duration of use in people who were receiving more than 5 mg daily. However, very low doses of less than 5 mg daily did not appear to increase the cardiovascular risk.
Other significant risk factors for a cardiovascular event included male sex, or having high blood pressure, high cholesterol, or systemic inflammation.
The authors think this supports the continued used of systemic glucocorticoids in people with rheumatoid arthritis, but it must be done carefully. This means balancing the risks and benefits for each person, and stopping or gradually reducing the dose to less than 5 mg a day as soon as possible.
Are these findings new?
No, there has been a previous study which showed an increased short-term cardiovascular risk even with low-dose glucocorticoid use in people with rheumatoid arthritis. But this new study now establishes that this higher risk lasts over a longer period of time than previously known.
What are the limitations of this study?
Because this was an observational study, it is not possible to confirm a causal relationship between glucocorticoid use and cardiovascular events. Additionally, some other factors such as smoking and body weight were not accounted for in the analysis.
What do the authors plan on doing with this information?
Because the relationship between glucocorticoid use and cardiovascular risk in rheumatoid arthritis is complicated, the authors plan to use an artificial intelligence model to help understand the complex interplay of multiple factors. The results of this could be used to help improve risk prediction. They also plan to investigate the effectiveness of very low-dose glucocorticoid treatment.
What does this mean for me?
If you have rheumatoid arthritis, it is very important that your cardiovascular risks are assessed regularly. You should also work to control your risk factors, such as stopping smoking and maintaining a healthy weight. An essential part of this is also taking an effective treatment to manage the systemic inflammation that is an underlying part of your rheumatoid arthritis. That might mean you need to take a glucocorticoid. These drugs are still an important treatment option, but in general their use should be minimised, and the associated cardiovascular risk should be discussed with you.
If you have been prescribed a glucocorticoid it is important that you do not stop taking it without medical advice, as there may be a special way of decreasing the dose before you can come off. If you have any concerns about your disease or its treatment, you should talk to your doctor or a healthcare professional involved in your care.
Date prepared: May 2024
Summary based on research article published on: January 2024
From: Summary from So H, et al. Time and dose-dependent effect of systemic glucocorticoids on major adverse cardiovascular event in patients with rheumatoid arthritis: a population-based study. Ann Rheum Dis 2023;82:1387–93. doi:10.1136/ard-2023-224185
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