Ann Intern Med 2020 Sep 22
Risk for Serious Infection With Low-Dose Glucocorticoids in Patients With Rheumatoid Arthritis : A Cohort Study.
Abstract
Background
Low-dose glucocorticoids are frequently used for the management of rheumatoid arthritis (RA) and other chronic conditions, but the safety of long-term use remains uncertain.
Objective
To quantify the risk for hospitalized infection with long-term use of low-dose glucocorticoids in patients with RA receiving stable disease-modifying antirheumatic drug (DMARD) therapy.
Design
Retrospective cohort study.
Setting
Medicare claims data and Optum's deidentified Clinformatics Data Mart database from 2006 to 2015.
Patients
Adults with RA receiving a stable DMARD regimen for more than 6 months.
Measurements
Associations between glucocorticoid dose (none, ≤5 mg/d, >5 to 10 mg/d, and >10 mg/d) and hospitalized infection were evaluated using inverse probability-weighted analyses, with 1-year cumulative incidence predicted from weighted models.
Results
247 297 observations were identified among 172 041 patients in Medicare and 58 279 observations among 44 118 patients in Optum. After 6 months of stable DMARD use, 47.1% of Medicare patients and 39.5% of Optum patients were receiving glucocorticoids. The 1-year cumulative incidence of hospitalized infection in Medicare patients not receiving glucocorticoids was 8.6% versus 11.0% (95% CI, 10.6% to 11.5%) for glucocorticoid dose of 5 mg or less per day, 14.4% (CI, 13.8% to 15.1%) for greater than 5 to 10 mg/d, and 17.7% (CI, 16.5% to 19.1%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). The 1-year cumulative incidence of hospitalized infection in Optum patients not receiving glucocorticoids was 4.0% versus 5.2% (CI, 4.7% to 5.8%) for glucocorticoid dose of 5 mg or less per day, 8.1% (CI, 7.0% to 9.3%) for greater than 5 to 10 mg/d, and 10.6% (CI, 8.5% to 13.2%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids).
Limitation
Potential for residual confounding and misclassification of glucocorticoid dose.
Conclusion
In patients with RA receiving stable DMARD therapy, glucocorticoids were associated with a dose-dependent increase in the risk for serious infection, with small but significant risks even at doses of 5 mg or less per day. Clinicians should balance the benefits of low-dose glucocorticoids with this potential risk.
Primary funding source
National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Related Questions
Would you escalate treatment for a clinically stable/asymptomatic lupus patient with persistent leukopenia/neutropenia, already on hydroxychloroquine?
The short answer is it depends on several variables most importantly, whether the patient has been experiencing recurrent infections. Additionally, the presence or absence of coincidental lymphocytopenia can be relevant. Worth mentioning that the most common hematologic manifestations in lupus are a...
What bDMARD would you choose for a patient with RA with high infection risk and inadequate response to cDMARDs?
This is an important question and a prime example of the "art of rheumatology" where we must balance the risk and benefit of targeted therapies of treating active RA and adverse events such as serious infection. Ideally, we would have many head-to-head trials of every agent adequately powered to ans...
How long do you continue steroid-sparing agents such as tocilizumab for GCA once the disease is in remission off steroids?
This is an excellent question and one we confront regularly. This is another of what I call “happy problems” because it is a consequence of increasing options for effective therapy for our patients.Tocilizumab is clearly an effective agent for some patients with giant cell arteritis (GCA), and patie...