“…In fact, avoidance of biologic DMARDs could potentially increase glucocorticoid requirements and possibly result in a worse safety profile in this high-risk population. Studies have suggested greater infection risk from moderate doses of glucocorticoids vs. biologics, in addition to effects on bone health, cardiovascular risk, and other outcomes which disproportionately affect older adults (13,23,24), yet the comparative risk of biologics and glucocorticoids (especially low-dose glucocorticoids) remain poorly understood and, especially considering the substantial cost differences of these therapies, is an important area of future research (25). Our findings cannot exclude the possibility that RA was less severe or more easily controlled in older patients, but we restricted our study to methotrexate-treated patients (excluding patients whose disease was controlled with only low-dose glucocorticoids or hydroxychloroquine for example) and we found that glucocorticoid use was similar at baseline and in follow-up.…”
Section: Discussionmentioning
confidence: 99%
“…Furthermore, existing studies of biologic use have not evaluated predictors of long-term glucocorticoid use, an important and common alternative treatment to bDMARDs. Glucocorticoid use is of particular interest because of substantial side effects even at modest doses and the uncertain safety of long-term low-dose therapy (13). Patient subgroups with low bDMARD use but high glucocorticoid use could potentially be at greater risk of adverse outcomes.…”
Objective.Biologic therapies can improve disease control for patients with rheumatoid arthritis (RA) but may be both overused and underused. We aimed to identify predictors of greater use of biologic therapies and to identify factors associated with persistent glucocorticoid use.Methods.Using national US Veteran’s Affairs databases 2005–2016, we identified patients with RA receiving a first-ever prescription of methotrexate (MTX), requiring ≥ 6 months of baseline data. We evaluated predictors of biologic therapy initiation within 2 years of starting MTX and factors associated with baseline and persistent glucocorticoid use at 6–12 months using multivariable models.Results.Among 17,415 patients starting MTX, 3263 patients received biologic therapy within 2 years (20.6% 2-yr incidence). In adjusted analyses, biologic use was substantially lower in older patients [e.g., aHR 0.20 (95% CI 0.16, 0.26) for patients ≥ 80 vs < 50] and patients with more comorbidities [aHR 0.79 (95% CI 0.72, 0.87) for Charlson score ≥ 3 vs < 3]. Patients with heart failure [aHR 0.68 (95% CI 0.54, 0.84)], cancer [aHR 0.78 (95% CI 0.66, 0.92)], or who were nonwhite [aHR 0.79 (95% CI 0.72, 0.87)] were also less likely to receive a biologic. In contrast, baseline and persistent glucocorticoid use was similar across age groups and more common in patients with greater comorbidity.Conclusion.Biologic therapy is initiated less frequently in patients with RA who are older, have more comorbidities, and who are nonwhite. While biologics may be avoided in older and sicker patients because of safety concerns, glucocorticoid use is similar regardless of age and is more frequent in patients with comorbidities, with implications for patient outcomes.
“…In fact, avoidance of biologic DMARDs could potentially increase glucocorticoid requirements and possibly result in a worse safety profile in this high-risk population. Studies have suggested greater infection risk from moderate doses of glucocorticoids vs. biologics, in addition to effects on bone health, cardiovascular risk, and other outcomes which disproportionately affect older adults (13,23,24), yet the comparative risk of biologics and glucocorticoids (especially low-dose glucocorticoids) remain poorly understood and, especially considering the substantial cost differences of these therapies, is an important area of future research (25). Our findings cannot exclude the possibility that RA was less severe or more easily controlled in older patients, but we restricted our study to methotrexate-treated patients (excluding patients whose disease was controlled with only low-dose glucocorticoids or hydroxychloroquine for example) and we found that glucocorticoid use was similar at baseline and in follow-up.…”
Section: Discussionmentioning
confidence: 99%
“…Furthermore, existing studies of biologic use have not evaluated predictors of long-term glucocorticoid use, an important and common alternative treatment to bDMARDs. Glucocorticoid use is of particular interest because of substantial side effects even at modest doses and the uncertain safety of long-term low-dose therapy (13). Patient subgroups with low bDMARD use but high glucocorticoid use could potentially be at greater risk of adverse outcomes.…”
Objective.Biologic therapies can improve disease control for patients with rheumatoid arthritis (RA) but may be both overused and underused. We aimed to identify predictors of greater use of biologic therapies and to identify factors associated with persistent glucocorticoid use.Methods.Using national US Veteran’s Affairs databases 2005–2016, we identified patients with RA receiving a first-ever prescription of methotrexate (MTX), requiring ≥ 6 months of baseline data. We evaluated predictors of biologic therapy initiation within 2 years of starting MTX and factors associated with baseline and persistent glucocorticoid use at 6–12 months using multivariable models.Results.Among 17,415 patients starting MTX, 3263 patients received biologic therapy within 2 years (20.6% 2-yr incidence). In adjusted analyses, biologic use was substantially lower in older patients [e.g., aHR 0.20 (95% CI 0.16, 0.26) for patients ≥ 80 vs < 50] and patients with more comorbidities [aHR 0.79 (95% CI 0.72, 0.87) for Charlson score ≥ 3 vs < 3]. Patients with heart failure [aHR 0.68 (95% CI 0.54, 0.84)], cancer [aHR 0.78 (95% CI 0.66, 0.92)], or who were nonwhite [aHR 0.79 (95% CI 0.72, 0.87)] were also less likely to receive a biologic. In contrast, baseline and persistent glucocorticoid use was similar across age groups and more common in patients with greater comorbidity.Conclusion.Biologic therapy is initiated less frequently in patients with RA who are older, have more comorbidities, and who are nonwhite. While biologics may be avoided in older and sicker patients because of safety concerns, glucocorticoid use is similar regardless of age and is more frequent in patients with comorbidities, with implications for patient outcomes.
“…Glucocorticoids remain a common therapy for the treatment of patients with rheumatoid arthritis (RA). Several studies have demonstrated that the addition of low‐dose glucocorticoids to therapy with disease modifying antirheumatic drugs (DMARDs) can improve patient outcomes (1–3), but glucocorticoids also carry risks, including infections, weight gain, diabetes mellitus, cardiovascular disease, and osteoporosis—especially at higher doses (4,5). Glucocorticoid prescribing for patients with rheumatoid arthritis varied widely among rheumatologists, even when considering differences in case mix.Patients who were seen by a rheumatologist who was a high glucocorticoid prescriber were substantially more likely to receive therapy with long‐term glucocorticoids.Compared to other patient factors, provider preference for glucocorticoids was one of the strongest predictors of long‐term glucocorticoid use.…”
Objective
Glucocorticoids are recommended for short‐term use in rheumatoid arthritis (RA), but many patients continue receiving long‐term therapy. We evaluated the variability in glucocorticoid prescribing across rheumatologists to inform interventions to limit long‐term glucocorticoid use to the lowest dose necessary.
Methods
Two cohorts were created using Medicare data from 2006 to 2015. Using cohort 1 (RA patients receiving disease‐modifying antirheumatic drugs [DMARDs]), we calculated each rheumatologist’s “provider preference” for glucocorticoids (frequency of use compared to other providers), using the ratio of observed to expected number of patients receiving glucocorticoids to account for case mix. In cohort 2 (RA patients receiving stable DMARD therapy), we evaluated whether provider preference for glucocorticoids could independently predict use of ≥5 mg/day of glucocorticoids 6–9 months after initiation of DMARD therapy.
Results
Using cohort 1 (1,272,644 yearly observations; 385,597 patients), we calculated provider preference among 6,875 rheumatologists (28,936 yearly observations). Provider preference was highly variable, with physicians at the lowest and upper quartiles prescribing glucocorticoids 33% less often to 31% more often (25th and 75th percentiles, respectively) than expected. In cohort 2 (155,539 patients receiving stable DMARD therapy), provider preference was strongly associated with glucocorticoid use ≥5 mg/day at 6–9 months, with a predicted probability of use of 22% (95% confidence interval [95% CI] 21.7–22.7) versus 11% (95% CI 10.2–10.9) for a patient seeing a provider in the highest versus lowest quintile of preference.
Conclusion
Glucocorticoid prescribing for RA varies greatly among rheumatologists, and provider preference is one of the strongest predictors of a patient’s long‐term glucocorticoid use. These findings raise quality of care concerns and highlight the need for stronger evidence to guide RA treatment.
“…However, considerable debate remains regarding dose, timing and duration of use [1][2][3][4]. Although GCs can be effective in decreasing the signs and symptoms of RA, and reducing radiographic progression [2,[5][6][7], they may be associated with a range of adverse effects including osteoporosis, hyperglycemia/diabetes mellitus, cardiovascular events and infections [3,5,6].…”
To date, the impact of background glucocorticoids (GC) on the efficacy and safety of abatacept or adalimumab in patients with active rheumatoid arthritis (RA) is not clearly established. This post hoc analysis of (AMPLE) trial (NCT00929864) compared efficacy and safety outcomes over 2 years in patients treated with abatacept or adalimumab plus background methotrexate (MTX), who continued GC (≤10 mg/day) versus those who were not receiving GC (no-GC). Of 646 randomized patients, 317 received abatacept + MTX (161 GC, 156 no-GC) and 326 received adalimumab + MTX (162 GC, 164 no-GC). At Year 2, the adjusted mean changes from baseline in Disease Activity Score (DAS28 C-reactive protein (CRP)) and Health Assessment Questionnaire-Disability Index (HAQ-DI) were not significantly different in the GC versus no-GC subgroups receiving abatacept or adalimumab. A similar proportion of patients achieved remission, HAQ-DI score improvement ≥0.3 and radiographic progression rates. No clinically meaningful safety differences were observed between GC versus no-GC subgroups either with abatacept or adalimumab. In patients with active RA of similar baseline disease activity treated with abatacept or adalimumab plus background MTX, there was no additional value of background GC on clinical, functional or radiographic outcomes over two years.
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