Patients With Rheumatoid Arthritis Are Wary of Prednisolone Usage

Patients with rheumatoid arthritis (RA) believe that prednisolone is a necessary medication, yet they are cautious about taking it due to the adverse effects, according to a study published in Rheumatology.¹

Prednisolone, an effective and fast-acting glucocorticoid agent, is the most common oral glucocorticoid prescribed in Australia. Its anti-inflammatory and disease-modifying properties have made it essential for managing RA since its introduction in the 1950s, with 50% of patients receiving it as their initial treatment and up to 30% of patients continuing to take it thereafter. Unfortunately, high-dose therapy and long-term use have been linked to adverse effects for patients. Therefore, it is generally limited to initial treatment, during disease flares, and in the interim while disease‐modifying antirheumatic drugs (DMARDs) are taking effect.

Investigators wanted to ascertain patients’ perspectives of glucocorticoid usage in order to improve clinical management, treatment adherence, and satisfaction. To accomplish this, a survey was created for patients with RA who were registered with the Australian Rheumatology Association Database (ARAD). Eligible patients had completed an ARAD questionnaire in the preceding 12 months. Demographics, medication use, patient-reported outcomes, and an Assessment of Quality of Life and Health Assessment Questionnaire (HAQ) were collected.

The survey was sent to 1010 participants, with a follow-up reminder sent out 2 weeks later for those who did not respond. Patients were asked about their personal history with prednisolone, including if they were currently taking the medicine or had denied it in the past. If they had declined the medication, they were asked a series of follow-up questions. Those who had taken prednisolone in the past also completed a Beliefs about Medicines Questionnaire (BMQ), which assessed a patient’s beliefs about overuse and harms of medicines in general as well as the necessity of prednisolone and any concerns about its usage. The responses were calculated using a 5-point Likert scale (1= strongly disagree to 5= strongly agree). The scores for patients with current prednisolone use and those who had a history of taking it were calculated separately. Responses mentioning adverse effects, stopping usage, or declining usage were analyzed in order to discover any themes or subthemes among participants.

The response rate was 79.6% (804/1010) and participants were mostly female (75.1%) with a median age of 61 years and a disease duration of 17 years. A total of 683 respondents reported prednisolone usage and 659 (96.5%) completed the additional BMQ survey. Of the responses, 251 (31.2%) had current prednisolone use, while 432 (53.7%) had previous use, and 121 (15.0%) had never taken the medication. Among those with previous prednisolone history, 103/121 (85.1%) were not offered the medication and 18/121 (14.8%) refused prednisolone when offered. Those who declined stated concerns about potential adverse effects, including weight gain and reading negative comments about prednisolone. There was no statistical difference in sex or education level between current and previous prednisolone users, but those with current usage tended to be older and had a longer disease duration with higher levels of pain, poorer disease control, and poorer health-related quality of life. Additionally, current users were more likely to be taking other DMARDs (41.4% versus 33.3%; P= 0.034). Those currently taking prednisolone had higher BMQ scores for prednisolone-specific necessity (3.6 versus 1.7; P <0.001) and concerns (2.7 versus 2.3; P <0.001). For previous prednisolone users, the most common responses for stopping the medication included adequate disease control (30.3%), adverse effects (25.2%), and predetermined short courses (21.3%). Adverse effects included weight gain (27.5%), osteoporosis (14.7%), and neuropsychiatric issues (13.8%).

“Although adequate disease control was the most commonly cited reason for stopping prednisolone, adverse effects were also a key consideration for both stopping and declining prednisolone,” investigators stated. “Prescribing practices were also an influencing factor, with prednisolone cessation commonly attributed to adequate disease control, prescribed short courses, and commencement of other agents.”

Limitations of the study included the survey-based approach and the fact that the population surveyed were older and more highly educated, which may not accurately reflect the wider RA population. Recall bias may also come into play, as the survey was geared towards evaluating lifetime use of prednisolone. Additionally, prednisolone was not specifically used in the wording of the study, although it is the most commonly prescribed glucocorticoid in Australia. Although patterns of use, dosing and duration of therapy were not collected, the response rate of participants strengthened the study. This can be used to indicate a generalizability of the findings, which were used to explore other aspects of patient-reported outcomes and experiences, as well as their personal considerations when deciding to start or stop prednisolone medications.

Roughly 85% of participants reported current or prior prednisolone usage. “The results of this study have highlighted that although cessation occurs with adequate disease control, adverse effects (namely, weight gain, osteoporosis, and neuropsychiatric effects) were a particularly important reason for stopping prednisolone in our cohort of patients with RA,” investigators concluded. “Clinicians should remain mindful of these common reasons for prednisolone cessation in shared decision‐making on treatment with patients. The small number of respondents who refused prednisolone without prior experience frequently cited concern about adverse effects, and further research to understand reasons for these beliefs should be explored.”

Reference:

Venter G, Tieu J, Black R, et al. Perspectives of Glucocorticoid Use in Patients with Rheumatoid Arthritis [published online ahead of print, 2021 Feb 20]. ACR Open Rheumatol. 2021;10.1002/acr2.11234. doi:10.1002/acr2.11234