Clinicians should exercise caution when administering treatment with glucocorticoids (GC) among patients with rheumatoid arthritis (RA), as these therapies may put them at increased risk for major adverse cardiovascular events (MACE), according to study results published in Annals of Rheumatic Disease.
Investigators assessed the effects of GC dose and duration of treatment on the risk for MACE among patients with RA.
A population-based retrospective cohort study was conducted, including adult patients without MACE who were diagnosed with RA from 2006 to 2015. Data were taken from a city-wide database in Hong-Kong. Patient follow-up continued until 2018.
The main study outcome of interest was initial incidence of MACE, defined as a composite of myocardial infarction, unstable angina, cerebrovascular accident, transient ischemic attack, and mortality. Daily GC dose and duration of use were calculated; to account for differences in anti-inflammatory effects among the types of GCs used, doses were converted into prednisolone-equivalents.
A total of 12,233 patients with RA were included in the analysis, accounting for 105,825 patient-years of follow-up (mean follow-up duration, 8.7 years).
Of these patients, 860 (7%) developed MACE during the study period, corresponding to an incidence rate of 8.13 per 1000 person-years.
After controlling for confounding factors, compared with receiving no GC treatment, receiving a daily prednisolone dose of at least 5 mg doubled the risk for MACE according to both erythrocyte sedimentation rate (ESR; hazard ratio [HR], 2.02; 95% CI, 1.72-2.37; P <.001) and C-reactive protein (CRP; HR ,1.87; 95% CI, 1.60-2.18; P <.001) models.
Risk for incident MACE was increased by 7% per month among patients receiving a daily prednisolone dose of at least 5 mg.
However, compared with receiving no GC treatment, receiving a daily prednisolone dose of less than 5 mg did not appear to effect MACE risk (ESR model: HR, 0.83; 95% CI, 0.60-1.14; CRP model: HR, 0.84; 95% CI, 0.62-1.15).
Study limitations included an absence of analysis of validated Disease Activity Scores and traditional CV risk factors, such as obesity, exercise, and family history. The observational nature of the study introduced the risk of channeling bias and prevented causality from being proven. Finally, GCs can affect MACE risk directly and indirectly by increasing inflammation, thereby resulting in treatment confounder feedback.
The study authors concluded, “We advocate to use systemic GC judiciously in RA, balancing the risks and benefits, and to discontinue or taper to prednisolone <5 mg daily as soon as possible.”
So H, Lam TO, Meng H, Lam SHM, Tam L-S. Time and dose-dependent effect of systemic glucocorticoids on major adverse cardiovascular event in patients with rheumatoid arthritis: a population-based study. Ann Rheum Dis. Published online July 24, 2023. doi: 10.1136/ard-2023-224185