Low-dose Glucocorticoid Initiation Observed in Severe Rheumatoid Arthritis Cases

In order to determine real-world prescribing patterns in patients with early rheumatoid arthritis, a new study evaluated the prevalence and incidence of glucocorticoid use, including disease activity trajectories among nonusers and users.

Led by Orit Schieir, PhD, University of Toronto, a team of investigators observed the initiation of low-dose glucocorticoid early in the course of new rheumatoid arthritis occurring mostly in cases of severe disease.

“Our results did not find significant differences in disease control 24 months later when comparing glucocorticoid users and nonusers, which is likely a reflection of their use among a subset of persons with more severe disease rather than a true lack of effectiveness,” investigators wrote.

Methods

Participants in the study who met inclusion criteria were adults aged 18 years or older enrolled in the Canadian Early Arthritis Cohort (CATCH) between January 2007 - March 2017.

As a multi-center prospective cohort study, CATCH included patients with early inflammatory arthritis followed in 22 rheumatology clinics in Canada. Early inflammatory arthritis was defined as 1 year or less of synovitis, two or more swollen joints, or one or more swollen metacarpophalangeal or proximal interphalangeal joints.

Data was collected at scheduled visits at 3, 6, 12, and 24 months. The team defined glucocorticoid as the data that prescription was written for prednisone, methylprednisolone, or hydrocortisone.

Additionally, Investigators used mixed-effects logistic regression for adjusted odds ratios (aORs) of escalation to biologics separately for 12 and 24 months.

Findings

The study included 1891 patients in the analysis, with 30% of CATCH participants receiving a glucocorticoid within 3-months of follow-up.

Data show 303 patients began steroids before entry into the study, with most starting within 2 or 3 months before enrollment (mean = 77 days). In comparison to nonusers, glucocorticoid users were older, less likely to be employed, and had a shorter disease duration.

Over 24 months, data show disease control improved, measured by a variety of disease activity measures. Despite early glucocorticoid patients starting at higher levels of disease activity, in each measure, there were no differences at the end of 24 months.

Then, in participants with ≥12 months of follow-up data, 159 (10%) initiated a biologic by 12 months, while participants with ≥24 months of follow-up, 199 (15%) initiated a biologic.

Data then show that in comparison to non-users, participants with early glucocorticoid use were more likely to be prescribed a biologic by 12 months (aOR = 2.4; 95% CI, 1.5 - 3.7) and 24 months (aOR = 1.9; 95% CI, 1.3 - 3.0).

Investigators noted that although clinical practice guidelines aimed to limit corticosteroid use to bridge therapy, 30% of patients who used oral glucocorticoids still used them 2 years later.

Takeaways

Schieir and colleagues observed that since the early use of steroids was often prolonged, it may perhaps represent a longer-term option rather than a true bridge therapy as patients wait for treatment escalation.

“Thus, in the Canadian clinical practice sites participating in this observational study, glucocorticoids were not used as short-term bridge therapy envisioned in practice recommendations,” they concluded.

The study, “A Bridge Too Far? Real-World Practice Patterns of Early Glucocorticoid Use in the Canadian Early Arthritis Cohort,” was published online in ACR Open Rheumatology.