Pneumonia Risk in Patients on DMARD, Glucocorticoid Therapy for Rheumatoid Arthritis

Kawther Elsouri

A team of investigators led by Kawther Elsouri, Nova Southeastern University Kiran Patel College of Osteopathic Medicine, evaluated pneumonia as an adverse event in patients with rheumatoid arthritis (RA) and documented the differences between those on disease-modifying antirheumatic drugs (DMARDs) as a monotherapy, in comparison with those on DMARDs and glucocorticoids (GCs) as combination therapy.

DMARDs are the most commonly used treatment for patients with rheumatoid arthritis but have been linked with pulmonary infections like pneumonia. This population is particularly vulnerable to negative outcomes when infected with pneumonia, and glucocorticoids are often used concurrently.

However, according to investigators, there's little known about the relationship between glucocorticoids and pneumonia in patients with rheumatoid arthritis. Based on the results of this study, patients on the combination therapy with glucocorticoids were more likely to develop pneumonia.

The Search

The study from August 2021 began with a search of 6 databases: Embase, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, International Pharmaceutical Abstracts (IPA), and ClinicalTrials.gov. Search terms included “glucocorticoids,” “rheumatoid arthritis,” “pneumonia,” and “respiratory tract infections."

Adult patients over the age of 18 with seropositive rheumatoid arthritis that were being treated with a combination of glucocorticoids and DMARDs, and contracted either bacterial, viral, or fungal pneumonia, met inclusion critieria. Glucocorticoids could be prednisone, methylprednisolone, or prednisolone, and DMARDs could be methotrexate, hydroxychloroquine, or sulfasalazine.

In the control group, patients were on a DMARD monotherapy regimen. Articles that were not in english, had less than 20 participants, case reports and literature reviews, had nonclinical subjects, or did not follow an established framework, were excluded.

The Analysis

After screening 3360 articles, 125 articles were then examined for full-text eligibility. Of those, investigators found 3 observational articles that were included in the meta-analysis.

Results from the statistical analysis showed that patients who received DMARD monotherapy were 95% less likely to develop pneumonia than the patients who were treated with DMARD and glucocorticoid combination therapy.

"Our data suggest that rheumatoid arthritis patients have a higher probability of developing pneumonia on combination therapy with GCs, compared to monotherapy with DMARDs," investigators wrote. "To our knowledge, our findings are the first to systematically review and statistically evaluate the relationship between the use of GCs and show an increased chance of developing pneumonia."

The study "Glucocorticoid use in rheumatoid arthritis patients and the onset of pneumonia: a systematic review and meta-analysis" was published in the Journal of Osteopathic Medicine.