Glucocorticoid use questioned in early RA
medwireNews: Adding glucocorticoids to conventional DMARDs as an initial treatment for early rheumatoid arthritis (ERA) does not appear to improve short- or long-term disease control, Belgian researchers report.
Patrick Durez (Université Catholique de Louvain, Brussels) and colleagues explain that “EULAR recommendations propose the initiation of glucocorticoids in combination with [conventional] DMARDs for every patient with ERA.”
Yet their data, published in Rheumatology, suggest that glucocorticoid “administration in ERA patients should be individually defined according to the balance of efficacy and complications.”
The study included 474 DMARD-naïve patients (mean age 49 years, 71% women) with ERA, of whom 38% initiated glucocorticoids at the same time as conventional DMARDs and 62% did not.
Durez and team found that the people who were given glucocorticoids at the same time as conventional DMARDs were older (50.6 vs 48.0 years) and had significantly higher mean baseline C-reactive protein (CRP) levels (2.9 vs 2.0 mg/dL) than those not given glucocorticoids.
They were also significantly more likely to be smokers (34.2 vs 23.3%), test negative for the anti-cyclic citrullinated peptide antibody (37.2 vs 27.6%), and be prescribed methotrexate as a monotherapy regimen rather than in combination with other DMARDs (70.6 vs 50.5%).
During 5 years of follow-up, there were no significant differences at any timepoint in DAS28-CRP, VAS pain, and HAQ scores between the people who received glucocorticoids at the start of treatment and those who did not.
The researchers also analyzed data for a subgroup of 139 patients who received a high cumulative glucocorticoid dose (>1 g prednisolone) during the 5-year period. As with the full cohort, glucocorticoid prescription was associated with older age, higher baseline CRP levels, and smoking, but was also more common in men and people with higher DAS28-CRP scores.
Unlike the overall cohort, however, DAS28-CRP, VAS pain, and HAQ scores remained significantly higher at 5 years among the people who received a high cumulative glucocorticoid dose relative to those who did not receive any glucocorticoids.
Individuals who received a high cumulative glucocorticoid dose also experienced more severe infections and were more likely to receive a biologic DMARD during follow-up than those not given glucocorticoids.
At the end of the study, 23.6% of participants in the glucocorticoid group were still receiving glucocorticoid treatment.
Durez et al conclude that their results “support the difficulty to define the best treatment option including [glucocorticoids] for each ERA patient.”
They add that the exploratory findings “are of importance in the ongoing debate about the use of [glucocorticoids] for ERA in daily practice.”
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