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21-09-2020 | Rheumatoid arthritis | News

Even low-dose glucocorticoids raise serious infection risk in RA patients

Author: Claire Barnard


medwireNews: Among patients with rheumatoid arthritis (RA) receiving stable DMARD treatment, long-term glucocorticoid use is associated with a dose-dependent increase in the risk for serious infection, with a “small but significant” risk even at the lowest doses, researchers report.

Therefore, “[c]linicians should avoid long-term use of higher-dose glucocorticoids and should weigh the benefits of low-dose therapy in individual patients with these potential risks,” Michael George (University of Pennsylvania, Philadelphia, USA) and colleagues write in the Annals of Internal Medicine.

The study drew on two US claims databases, Medicare (representing publically insured patients aged 65 years and older) and Optum (representing commercially insured patients), to evaluate the risk for infection occurring during an acute care hospitalization over a total of 305,576 medication courses in 216,159 people with RA who were undergoing stable DMARD treatment. Approximately half of the medication courses included biologics or Janus kinase inhibitors.

In all, 47.1% of the 172,041 Medicare patients and 39.5% of the 44,118 Optum patients were taking glucocorticoids after 6 months of stable DMARD use, most commonly at a dose of 5 mg/day or lower.

George and team observed rising rates of hospitalized infection with increasing glucocorticoid doses in the Medicare cohort, at 8.4 per 100 person–years for those not taking the agents, and 13.5, 21.5, and 31.6 per 100 person–years for those taking low-dose (≤5 mg/day), medium-dose (>5–10 mg/day), and high-dose (>10 mg/day) glucocorticoids, respectively.

In a model adjusting for potentially confounding factors, people taking any dose of glucocorticoids had a significantly higher risk for hospitalized infection than those not taking glucocorticoids, with a hazard ratio (HR) of 1.29 for those in the low-dose group, 1.72 for those in the medium-dose group, and 2.16 for those in the high-dose group.

The researchers describe a similar pattern of results for the Optum cohort, with corresponding HRs of 1.32, 2.07, and 2.76.

“To put the observed risk into perspective, the risk for hospitalized infection associated with 5 mg or less of glucocorticoids per day was similar to the risk associated with biologic therapies in prior studies,” write the study authors. They note that this “may be helpful when counseling patients who require higher doses of glucocorticoids but who are hesitant to start a biologic treatment because of infection concerns.”

And the team concludes: “Our results support guideline recommendations to minimize the long-term use of glucocorticoids and attempt tapering, but the risks of low-dose glucocorticoids may be acceptable in patients who are obtaining substantial benefit and who have increased disease activity when attempts are made to taper.”

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Ann Intern Med 2020; doi:10.7326/M20-1594