Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020

Xie, Wenhui; Li, Guangtao; Hao, Yanjie; Gui, Yanni; Wang, Yu; Deng, Xuerong; Zhao, Juan; Geng, Yan; Ji, Lanlan; Zhang, Xiaohui; Song, Zhibo; Zhang, Zhuoli

doi:10.1136/annrheumdis-2021-220112

Cited by 20 publications

(24 citation statements)

References 34 publications

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“… 6 However, less than half of the cohort initially treated with glucocorticoids achieved definitive discontinuation. These findings are in line with the modern literature on patients with RA, 11 further highlighting the generalisability of our results. Indeed, glucocorticoids withdrawal might be challenging in many patients due to recurrent disease flares.…”

Section: Discussionsupporting

confidence: 92%

“… 8–10 Approximately 50% of patients with early RA attain glucocorticoids discontinuation at 3 years but about 30% of them will have a flare within the next 6 months from discontinuation. 11 Indeed, tapering and discontinuing glucocorticoids has been associated with higher risk of flare but the dosage at which the flare happens is unpredictable and mostly not known. 9 In addition, the EULAR definition for low-dose glucocorticoids (ie, ≤7.5 mg/day) is arbitrary and based on questionable assumptions, which are not related to efficacy on disease activity but mostly on common sense and frequency of adverse events.…”

Section: Introductionmentioning

confidence: 99%

“…[8][9][10] Approximately 50% of patients with early RA attain glucocorticoids discontinuation at 3 years but about 30% of them will have a flare within the next 6 months from discontinuation. 11 Indeed, tapering and discontinuing…”

Section: Introductionmentioning

confidence: 99%

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Tapering glucocorticoids and risk of flare in rheumatoid arthritis on biological disease-modifying antirheumatic drugs (bDMARDs)

et al. 2023

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IntroductionGlucocorticoids are still a mainstream of rheumatoid arthritis (RA) treatment. Reducing glucocorticoids should be attempted in all patients. However, choosing the right tapering strategy is challenging. The primary aim of our study is to determine the dose–response association between glucocorticoid tapering and risk of flare in RA.MethodsWe conducted a case-crossover study to determine the factors associated to higher risk of flare in patients with RA. In case-crossover studies time-varying factors are assessed before events (hazard periods) and before control periods. We defined hazard periods as the 6 months immediately preceding flares of RA. Control periods were the 6 months prior to visits without flare. Exposure of interest was the tapering of glucocorticoids to various doses.Results508 patients with RA were included in the study and 267 (52.5%) had at least a flare and served as the case-crossover study population. 1545 visits were available for analysis and 345 (22.3%) flares were recorded. Discontinuation of glucocorticoids (ie, tapering to doses of 0 mg/day) and tapering to 0–2.5 mg/day was associated with higher risk of flare (adjusted OR (aOR) of 1.45, 95% CI: 1.13 to 2.24 and aOR of 1.37; 95% CI: 1.06 to 2.01, respectively). Tapering to doses >2.5 mg/day was not associated with significantly higher risk of flare.ConclusionsWe found that tapering to doses of >2.5 mg/day was generally effective in terms of risk of flare. Flare risk was higher when glucocorticoids were tapered to doses ≤2.5 mg/day. Our study might help design new tapering strategies in patients with RA on biological disease-modifying antirheumatic drugs.

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Section: Discussionsupporting

confidence: 92%

Section: Introductionmentioning

confidence: 99%

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Tapering glucocorticoids and risk of flare in rheumatoid arthritis on biological disease-modifying antirheumatic drugs (bDMARDs)

et al. 2023

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“…One study that was published in 2021 did fit our research question regarding the use of GC as bridging therapy, but only reported cumulative probabilities over time. In the early DMARD naïve patients with RA, the cumulative probability of GC discontinuation was 29.9% at 12 months and 53.5% at 24 months 27…”

Section: Resultsmentioning

confidence: 99%

Systematic literature review of observational cohorts and clinical trials into the success rate of glucocorticoid discontinuation after their use as bridging therapy in patients with rheumatoid arthritis

Ouwerkerk

Palmowski

Nevins³

et al. 2022

Ann Rheum Dis

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ObjectiveTo investigate the success rate of glucocorticoid (GC) discontinuation during follow-up in observational cohorts and clinical trials using temporary GC as part of initial therapy (‘bridging’) in newly diagnosed patients with rheumatoid arthritis (RA).MethodsSystematic literature searches were conducted to identify observational cohorts and clinical trials including patients with RA treated with initial GC bridging therapy, defined as discontinuation of GC within 1 year. Patient percentages still using GC were considered the reverse of successful discontinuation. Random effects meta-analyses were performed stratified by time point.ResultsThe scoping literature search for observational cohort studies could not identify studies answering the research question. The literature search for clinical trials identified 7160 abstracts, resulting in 10 included studies, with varying type and dose of GC and varying tapering schedules, of which 4 reported sufficient data on GC discontinuation or use after the bridging phase. The pooled proportion of patients who were still or again using GC was 22% (95% CI 8% to 37%, based on four trials) at 12 months and 10% at 24 months (95% CI −1 to 22, based on two trials). Heterogeneity was substantial (I²≥65%).ConclusionThe success rate of GC discontinuation after bridging as part of initial treatment of RA has been described in a limited number of studies. Reports on observational cohorts did not answer the research question. In clinical trials, protocolised discontinuation was mostly successful, although 22% of the patients who started GC bridging therapy still or again used GC at 12 months, and 10% at 24 months.

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“…The key point in determining whether the net effect of GC is detrimental or not to bone mass lies in the duration of GC exposure. In our previous TARRA cohort study, GC was used with a median time of 27 months in RA patients ( 44 ). It might be more beneficial to use GC with a short course.…”

Section: Discussionmentioning

confidence: 99%

Impact of Treat-to-Target Therapy on Bone Mineral Density Loss in Patients With Rheumatoid Arthritis: A Prospective Cohort Study

et al. 2022

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BackgroundOsteoporosis is a common comorbidity of rheumatoid arthritis (RA). Although RA disease activity has been demonstrated to be associated with bone loss in previous studies, most of them were cross-sectional studies and not in the context of treat-to-target (T2T) strategies.ObjectivesThis study aimed to evaluate the association of disease activity with bone mineral density (BMD) changes in the context of T2T strategies in a prospective RA cohort.MethodsRA patients were enrolled from a prospective CENTRA cohort of Peking University First Hospital. The follow-ups have been scheduled every 3 to 6 months. BMD was repeated at baseline, 1 year, and then every other year. Demographics, baseline clinical features, laboratory data, and medications at each visit were recorded. Time-adjusted mean disease activity scores were adopted to reflect the overall disease activity during follow-up. The influence of univariable associations between predictors and BMD was investigated using linear regression.ResultsA total of 268 patients were included in our analysis. Their mean age was 50 (12.9) years, and 224 (83.6%) were women. The median (IQR) disease duration was 48.7 (107.6) months. Osteoporosis in the lumbar spine was observed in 23.1% of patients and 9.3% in the femoral neck at enrollment. Older age, higher SDAI score, and lower BMI were associated with osteoporosis at baseline. The proportion of patients who achieved DAS28-ESR, CDAI, and SDAI remission or LDA at the end of the first year was 71.5%, 68.8%, and 67.4%, respectively. Reevaluations of BMD at 1 year were applied to 144 patients. Mean decreases of BMDs were 1.75% at the lumbar spine and 1.40% at the femoral neck at 1 year from baseline, respectively. Patients who achieved remission had less yearly bone loss in the lumbar spine (p = 0.036). Female gender was identified as a risk factor in the multiple linear regression analyses, and lower disease activity and bisphosphonates were protective factors of continuous bone loss.ConclusionDisease activity is associated with bone loss in RA patients in the context of T2T strategies, and those who achieved remission had less yearly bone loss.

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Dynamical trajectory of glucocorticoids tapering and discontinuation in patients with rheumatoid arthritis commencing glucocorticoids with csDMARDs: a real-world data from 2009 to 2020

Cited by 20 publications

References 34 publications

Tapering glucocorticoids and risk of flare in rheumatoid arthritis on biological disease-modifying antirheumatic drugs (bDMARDs)

Tapering glucocorticoids and risk of flare in rheumatoid arthritis on biological disease-modifying antirheumatic drugs (bDMARDs)

Systematic literature review of observational cohorts and clinical trials into the success rate of glucocorticoid discontinuation after their use as bridging therapy in patients with rheumatoid arthritis

Impact of Treat-to-Target Therapy on Bone Mineral Density Loss in Patients With Rheumatoid Arthritis: A Prospective Cohort Study

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