Is it possible to discontinue glucocorticoids in rheumatoid arthritis with the use of synthetic disease-modifying antirheumatic drugs?
DOI:
https://doi.org/10.14739/2310-1210.2023.4.277503Keywords:
rheumatoid arthritis, glucocorticoids, disease-modifying therapyAbstract
The aim of the work is to study the possibility of glucocorticoid (GC) discontinuation or their target dose achievement in patients (pts) with rheumatoid arthritis (RA) receiving conventional synthetic disease-modifying antirheumatic drugs (DMARDs).
Materials and methods. 270 pts with RA (women – 86.6 %) aged 51.2 ± 0.71 years, with a disease duration of 50.20 ± 3.82 months were examined. Rheumatoid factor was found in 64.8 % of individuals, anti-cyclic citrullinated peptide (ACCP) antibodies – in 66.6 %. DMARD therapy included methotrexate (n = 91), leflunomide (n = 95), sulfasalazine (n = 51), hydroxychloroquine (n = 3) or its combination (n = 126). The SPSS (version 22.0) software was used for the statistical analysis.
Results. During the 3-year study, GC was withdrawn in 33 % of pts in the period from 3 to 30 months (mostly in the first 6 moths). Among those who continued to take GC, the target dose (<7.5 mg/d) was achieved only in 32.6 % of pts. Among pts continuously receiving GC, compared with pts who discontinued GC therapy, there were significantly more women (89.5 % vs. 80.8 %), ACCP-positive pts (88.4 % vs. 55.0 %), with higher DAS-ESR values (5.29 ± 0.10 vs. 4.84 ± 0.15) and more pronounced structural changes on the SHS scale (43.40 ± 2.42 vs. 32.40 ± 2.71).
According to the logistic regression analysis, female sex (OR 2.39), elderly pts (OR 1.02), ACCP-positivity (OR 3.73), disease activity by DAS-ESR (OR 1.19) and structural joint changes (OR 1.01) were significantly associated with the risk of continuing GC treatment. Only the initial dose of GC ≥7.5 mg/d was associated with the inability to reach the target dose of GC during the entire follow-up period (OR 6.32).
Conclusions. Despite of the treatment with conventional synthetic DMARD, only a third of RA pts can withdraw GC, mostly in the first 6 months. For the pts who continue taking GC, the target dose can be achieved in 33 % of them. Independent predictors of the impossibility to withdraw GC are female sex, old age, ACCP-positivity, higher RA activity according to DAS-ESR and more pronounced joint destruction in early stages. An initial GC dose ≥7.5 mg/d is a negative prognostic factor in achieving the target dose.
References
Albrecht, K., Callhoff, J., Schneider, M., & Zink, A. (2015). High variability in glucocorticoid starting doses in patients with rheumatoid arthritis: observational data from an early arthritis cohort. Rheumatology international, 35(8), 1377-1384. https://doi.org/10.1007/s00296-015-3229-x
Arnett, F. C., Edworthy, S. M., Bloch, D. A., McShane, D. J., Fries, J. F., Cooper, N. S., Healey, L. A., Kaplan, S. R., Liang, M. H., & Luthra, H. S. (1988). The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis and rheumatism, 31(3), 315-324. https://doi.org/10.1002/art.1780310302
Black, R. J., Lester, S., Buchbinder, R., Barrett, C., Lassere, M., March, L., Whittle, S., & Hill, C. L. (2017). Factors associated with oral glucocorticoid use in patients with rheumatoid arthritis: a drug use study from a prospective national biologics registry. Arthritis research & therapy, 19(1), 253. https://doi.org/10.1186/s13075-017-1461-3
Black, R. J., Joseph, R. M., Brown, B., Movahedi, M., Lunt, M., & Dixon, W. G. (2015). Half of U.K. patients with rheumatoid arthritis are prescribed oral glucocorticoid therapy in primary care: a retrospective drug utilisation study. Arthritis research & therapy, 17, 375. https://doi.org/10.1186/s13075-015-0895-8
Boers, M. (2019). Glucocorticoids for rheumatoid arthritis in the era of targeted therapies. Reumatologia clinica, 15(6), 311-314. https://doi.org/10.1016/j.reuma.2019.05.003
Cardiel, M. H., Pons-Estel, B. A., Sacnun, M. P., Wojdyla, D., Saurit, V., Marcos, J. C., Pinto, M. R., Cordeiro de Azevedo, A. B., da Silveira, I. G., Radominski, S. C., Ximenes, A. C., Massardo, L., Ballesteros, F., Rojas-Villarraga, A., Oñate, R. V., Hernandez, M. P., Esquivel-Valerio, J. A., García-De La Torre, I., Khoury, V. J., Millán, A., … GLADAR (2012). Treatment of early rheumatoid arthritis in a multinational inception cohort of Latin American patients: the GLADAR experience. Journal of clinical rheumatology, 18(7), 327-335. https://doi.org/10.1097/RHU.0b013e31826d6610
Gotzsche, P. C., & Johansen, H. K. (2004). Short-term low-dose corticosteroids vs placebo and nonsteroidal antiinflammatory drugs in rheumatoid arthritis. The Cochrane database of systematic reviews, 2005(3), CD000189. https://doi.org/10.1002/14651858.CD000189.pub2
Hardy, R., & Cooper, M. S. (2018). Unravelling how glucocorticoids work in rheumatoid arthritis. Nature reviews. Rheumatology, 14(10), 566-567. https://doi.org/10.1038/s41584-018-0079-4
Inoue, M., Kanda, H., Tateishi, S., & Fujio, K. (2020). Factors associated with discontinuation of glucocorticoids after starting biological disease-modifying antirheumatic drugs in rheumatoid arthritis patients. Modern rheumatology, 30(1), 58-63. https://doi.org/10.1080/14397595.2018.1553264
Maassen, J. M., Dos Santos Sobrín, R., Bergstra, S. A., Goekoop, R., Huizinga, T. W. J., & Allaart, C. F. (2021). Glucocorticoid discontinuation in patients with early rheumatoid and undifferentiated arthritis: a post-hoc analysis of the BeSt and IMPROVED studies. Annals of the rheumatic diseases, 80(9), 1124-1129. https://doi.org/10.1136/annrheumdis-2021-220403
Makol, A., Davis, J. M., 3rd, Crowson, C. S., Therneau, T. M., Gabriel, S. E., & Matteson, E. L. (2014). Time trends in glucocorticoid use in rheumatoid arthritis: results from a population-based inception cohort, 1980-1994 versus 1995-2007. Arthritis care & research, 66(10), 1482-1488. https://doi.org/10.1002/acr.22365
McKeown, E., Bykerk, V. P., De Leon, F., Bonner, A., Thorne, C., Hitchon, C. A., Boire, G., Haraoui, B., Ferland, D. S., Keystone, E. C., Pope, J. E., & CATCH Investigators (2012). Quality assurance study of the use of preventative therapies in glucocorticoid-induced osteoporosis in early inflammatory arthritis: results from the CATCH cohort. Rheumatology (Oxford, England), 51(9), 1662-1669. https://doi.org/10.1093/rheumatology/kes079
Roubille, C., Rincheval, N., Dougados, M., Flipo, R. M., Daurès, J. P., & Combe, B. (2017). Seven-year tolerability profile of glucocorticoids use in early rheumatoid arthritis: data from the ESPOIR cohort. Annals of the rheumatic diseases, 76(11), 1797-1802. https://doi.org/10.1136/annrheumdis-2016-210135
Sanmartí, R., Tornero, J., Narváez, J., Muñoz, A., Garmendia, E., Ortiz, A. M., Abad, M. A., Moya, P., Mateo, M. L., Reina, D., Salvatierra-Ossorio, J., Rodriguez, S., Palmou-Fontana, N., Ruibal-Escribano, A., & Calvo-Alén, J. (2020). Efficacy and safety of glucocorticoids in rheumatoid arthritis: Systematic literature review. Eficacia y seguridad de los glucocorticoides en la artritis reumatoide: revisión sistemática de la literatura. Reumatologia clinica, 16(3), 222-228. https://doi.org/10.1016/j.reuma.2018.06.007
Singh, J. A., Saag, K. G., Bridges, S. L., Jr, Akl, E. A., Bannuru, R. R., Sullivan, M. C., Vaysbrot, E., McNaughton, C., Osani, M., Shmerling, R. H., Curtis, J. R., Furst, D. E., Parks, D., Kavanaugh, A., O'Dell, J., King, C., Leong, A., Matteson, E. L., Schousboe, J. T., Drevlow, B., … American College of Rheumatology (2016). 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis care & research, 68(1), 1-25. https://doi.org/10.1002/acr.22783
Smolen, J. S., Landewé, R., Bijlsma, J., Burmester, G., Chatzidionysiou, K., Dougados, M., Nam, J., Ramiro, S., Voshaar, M., van Vollenhoven, R., Aletaha, D., Aringer, M., Boers, M., Buckley, C. D., Buttgereit, F., Bykerk, V., Cardiel, M., Combe, B., Cutolo, M., van Eijk-Hustings, Y., … van der Heijde, D. (2017). EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Annals of the rheumatic diseases, 76(6), 960-977. https://doi.org/10.1136/annrheumdis-2016-210715
Smolen, J. S., Landewé, R., Breedveld, F. C., Buch, M., Burmester, G., Dougados, M., Emery, P., Gaujoux-Viala, C., Gossec, L., Nam, J., Ramiro, S., Winthrop, K., de Wit, M., Aletaha, D., Betteridge, N., Bijlsma, J. W., Boers, M., Buttgereit, F., Combe, B., Cutolo, M., … van der Heijde, D. (2014). EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2013 update. Annals of the rheumatic diseases, 73(3), 492-509. https://doi.org/10.1136/annrheumdis-2013-204573
Smolen, J. S., Landewé, R. B. M., Bijlsma, J. W. J., Burmester, G. R., Dougados, M., Kerschbaumer, A., McInnes, I. B., Sepriano, A., van Vollenhoven, R. F., de Wit, M., Aletaha, D., Aringer, M., Askling, J., Balsa, A., Boers, M., den Broeder, A. A., Buch, M. H., Buttgereit, F., Caporali, R., Cardiel, M. H., … van der Heijde, D. (2020). EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Annals of the rheumatic diseases, 79(6), 685-699. https://doi.org/10.1136/annrheumdis-2019-216655
Van der Heijde, D. (1999). How to read radiographs according to the Sharp/van der Heijde method. The Journal of rheumatology, 26(3), 743-745.
Xie, W., Huang, H., Li, G., Hao, Y., Gui, Y., Wang, Y., Deng, X., Zhao, J., Geng, Y., Ji, L., Zhang, X., Song, Z., & Zhang, Z. (2021). Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020. Annals of the rheumatic diseases, 80(8), 997-1003. https://doi.org/10.1136/annrheumdis-2021-220112
Yagiz, B., Coskun, B. N., Pehlivan, Y., Dalkilic, E., Kiraz, S., Yazisiz, V., Kucuksahin, O., Erden, A., Kanitez, N. A., Kimyon, G., Emmungil, H., Bilge, S. Y., Kasifoglu, T., Bes, C., Bolek, E. C., Bilgin, E., Karatas, A., Kelesoglu, B., Ersozlu, D., Gonullu, E. O., … Kalyoncu, U. (2021). In the era of disease-modifying antirheumatic drugs, how close are we to treating rheumatoid arthritis without the use of glucocorticoids?. Rheumatology international, 41(11), 1915-1924. https://doi.org/10.1007/s00296-021-04939-8
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