Most early glucocorticoid treatment was targeted to patients with the most severe or active disease, according to study results from Canada.
A recent study examining the use of glucocorticoids in the earlier stages of rheumatoid arthritis (RA) treatment found that most treatment was targeted to patients with the most severe or active disease.
Current evidence from clinical trials suggests benefit to using synthetic glucocorticoids for rapid symptom control and to prevent joint destruction, but they also carry a higher risk for infection and side effects such weight gain, osteoporosis, and metabolic dysregulation. However, in real-world settings, RA treatment strategies may vary due to patient comorbidities.
This study was conducted to gain improved clarity around the use of glucocorticoids in early RA in Canada by examining a large population with longitudinal follow-up via real-world prescribing practices.
Data came from the Canadian Early Arthritis Cohort (CATCH), a multicenter prospective cohort study of patients with early inflammatory arthritis followed in 22 rheumatology clinics. Consistent with American College of Rheumatology criteria, early inflammatory arthritis was defined as 1 year or less of synovitis, 2 or more swollen joints, or 1 or more swollen finger joints with at least 1 of the following: rheumatoid factor or anti–citrullinated protein antibody positivity, 45 minutes or more of morning stiffness, patient-reported improvement with nonsteroidal anti-inflammatory drugs, or a positive metatarsophalangeal squeeze test.
Adults with RA diagnosed within the past year were stratified on the basis of whether a person was prescribed oral glucocorticoids within 3 months of study entry, and disease activity was compared over 24 months.
Mixed-effects logistic regression was used for adjusted odds ratios (aORs) of escalation to biologics separately for 12 and 24 months.
After excluding 89 patients who were already on a biologic by month 3, 1891 individuals were included in the analysis. Of those, 30% received oral steroids within 3 months of follow-up.
Early glucocorticoid use was linked with the need to intensify therapy, and despite clinical practice guidelines to limit corticosteroid use to bridge therapy, 30% of patients who used oral glucocorticoids still used them 2 years later.
Participants starting oral glucocorticoids early were more likely to be on a biologic at 12 months (aOR = 2.4; 95% CI, 1.5-3.7) and 24 months (aOR = 1.9; 95% CI, 1.3-3.0) compared with those not starting glucocorticoids early.
Patients initiating glucocorticoids earlier were older, were less likely to be employed, and had shorter disease duration and higher disease activity.
The use of early steroids were often indicative of more active baseline disease as well as the need for progression to biologics.
The authors wrote they believe this is the first study to show that in Canadian early RA care, steroid use is mostly directed to patients with severe and active disease.
As expected, disease activity improved over follow-up for all groups, consistent with the treat-to-target paradigm in Canada.
Nearly 1 in 3 people who began glucocorticoids earlier were still taking them 2 years later.
“One possible explanation for the findings is that the early use of glucocorticoids in more active disease and severe symptoms may reflect a clinician’s concerns about exposing their patients with less active baseline disease to additional side effects if there is not a strong indication for steroid use,” wrote the authors, who added that their results give additional insight into how glucocorticoids are used and in whom.
Andersen KM, Schieir O, Valois MF, et al. A bridge too far? Real-world practice patterns of early glucocorticoid use in the Canadian early arthritis cohort. ACR Open Rheumatol. Published online October 28, 2021. doi.org/10.1002/acr2.11334