Oral glucocorticoids and incidence of hypertension in people with chronic inflammatory diseases: a population-based cohort study

Mebrahtu, Teumzghi F; Morgan, Ann W; West, Robert; Stewart, Paul M.; Pujades-Rodríguez, Mar

doi:10.1503/cmaj.191012

Cited by 55 publications

(37 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…We defined several time-variant glucocorticoid variables to quantify current and cumulative drug exposure: (1) ever use from 1 year (2 or 5 years in additional sensitivity analyses) prior to follow-up start (binary variable); (2) current daily use (i.e., whether or not the patient was prescribed glucocorticoids at a given time point [binary variable]); (3) current daily dose per 5 mg/day with 0 value when medication was not prescribed (continuous and categorical variables: non-use, 1 to 4.9 mg, 5.0 to 14.9 mg, 15.0 to 24.9 mg, �25.0 mg/day); and (4) cumulative dose since 1 year (2 or 5 years in additional sensitivity analyses) prior to follow-up start per 1,000 mg (i.e., sum of the total dose prescribed up to that point divided by 1,000; considered as continuous and categorical variables: non-use, 1 to 959 mg, 960 to 3,054 mg, 3,055 to 7,299 mg, and �7,300 mg; as defined previously [19][20][21][22]).…”

Section: Oral Glucocorticoid Exposurementioning

confidence: 99%

Dose-dependent oral glucocorticoid cardiovascular risks in people with immune-mediated inflammatory diseases: A population-based cohort study

et al. 2020

Self Cite

View full text Add to dashboard Cite

Background Glucocorticoids are widely used to reduce disease activity and inflammation in patients with a range of immune-mediated inflammatory diseases. It is uncertain whether or not low to moderate glucocorticoid dose increases cardiovascular risk. We aimed to quantify glucocorticoid dose-dependent cardiovascular risk in people with 6 immune-mediated inflammatory diseases. Methods and findings We conducted a population-based cohort analysis of medical records from 389 primary care practices contributing data to the United Kingdom Clinical Practice Research Datalink (CPRD), linked to hospital admissions and deaths in 1998–2017. We estimated time-variant daily and cumulative glucocorticoid prednisolone-equivalent dose-related risks and hazard ratios (HRs) of first all-cause and type-specific cardiovascular diseases (CVDs). There were 87,794 patients with giant cell arteritis and/or polymyalgia rheumatica (n = 25,581), inflammatory bowel disease (n = 27,739), rheumatoid arthritis (n = 25,324), systemic lupus erythematosus (n = 3,951), and/or vasculitis (n = 5,199), and no prior CVD. Mean age was 56 years and 34.1% were men. The median follow-up time was 5.0 years, and the proportions of person–years spent at each level of glucocorticoid daily exposure were 80% for non-use, 6.0% for <5 mg, 11.2% for 5.0–14.9 mg, 1.6% for 15.0–24.9 mg, and 1.2% for ≥25.0 mg. Incident CVD occurred in 13,426 (15.3%) people, including 6,013 atrial fibrillation, 7,727 heart failure, and 2,809 acute myocardial infarction events. One-year cumulative risks of all-cause CVD increased from 1.4% in periods of non-use to 8.9% for a daily prednisolone-equivalent dose of ≥25.0 mg. Five-year cumulative risks increased from 7.1% to 28.0%, respectively. Compared to periods of non-glucocorticoid use, those with <5.0 mg daily prednisolone-equivalent dose had increased all-cause CVD risk (HR = 1.74; 95% confidence interval [CI] 1.64–1.84; range 1.52 for polymyalgia rheumatica and/or giant cell arteritis to 2.82 for systemic lupus erythematosus). Increased dose-dependent risk ratios were found regardless of disease activity level and for all type-specific CVDs. HRs for type-specific CVDs and <5.0-mg daily dose use were: 1.69 (95% CI 1.54–1.85) for atrial fibrillation, 1.75 (95% CI 1.56–1.97) for heart failure, 1.76 (95% CI 1.51–2.05) for acute myocardial infarction, 1.78 (95% CI 1.53–2.07) for peripheral arterial disease, 1.32 (95% CI 1.15–1.50) for cerebrovascular disease, and 1.93 (95% CI 1.47–2.53) for abdominal aortic aneurysm. The lack of hospital medication records and drug adherence data might have led to underestimation of the dose prescribed when specialists provided care and overestimation of the dose taken during periods of low disease activity. The resulting dose misclassification in some patients is likely to have reduced the size of dose–response estimates. Conclusions In this study, we observed an increased risk of CVDs associated with glucocorticoid dose intake even at lower doses (<5 mg) in 6 immune-mediated diseases. These results highlight the importance of prompt and regular monitoring of cardiovascular risk and use of primary prevention treatment at all glucocorticoid doses.

show abstract

Section: Oral Glucocorticoid Exposurementioning

confidence: 99%

Dose-dependent oral glucocorticoid cardiovascular risks in people with immune-mediated inflammatory diseases: A population-based cohort study

et al. 2020

Self Cite

View full text Add to dashboard Cite

show abstract

“…regional musculoskeletal complaints) not necessarily relating to activity of the index disease [ 34 , 35 ]. This likely perpetuates corticosteroid prescribing despite guidelines and trial-based evidence of associated diabetes, hypertension and cardiovascular disease risk in RA patients [ 9 , 10 , 12 ]. It may also mask symptoms of poor RA disease control.…”

Section: Discussionmentioning

confidence: 99%

Changes in the pharmacological management of rheumatoid arthritis over two decades

et al. 2021

Self Cite

View full text Add to dashboard Cite

Objectives To assess whether modern management of rheumatoid arthritis (RA) has reduced the prescription of oral corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs) and to evaluate use of pharmacological prophylaxis strategies. Methods Using the Clinical Practice Research Datalink, we explored long-term (≥3/12 months; ≥6/12 in sub-analyses) disease modifying antirheumatic drug (DMARD), corticosteroid and NSAID prescribing (annually, in the year post-diagnosis and across the patient’s life-course to 15 years post-diagnosis), annual proportion with co-prescribing for prophylaxis of associated bone (corticosteroids, women only) and gastrointestinal (NSAIDs) comorbidity. Results Reported incidence of RA was 5.98 (±0.37) per 10 000 person-years and prevalence was 0.91% (±0.014) in 2017. In 71 411 RA patients, long-term DMARD prescribing initially rose post-diagnosis from 41.6% in 1998–67.9% in 2009. Corticosteroid prescribing changed little, overall (22.2% in 1998, 19.1% in 2016; incident risk ratio (IRR) 0.92, 95% CI 0.82–1.03) and across the life-course from the first to fifteenth year (22.2% to 16.9%). NSAID prescribing declined from 57.7% in 1998, and significantly so from 2008, to 27.1% in 2016 (IRR 0.50, 95% CI 0.44–0.56). This continued across the life-course (41.2% to 28.4%). Bone prophylaxis increased to 68.1% in 2008 before declining to 56.4% in 2017; gastrointestinal prophylaxis increased from 11.5% in 1998–62.6% in 2017. Sub-analyses showed consistent patterns. Conclusion Despite modern treatment strategies, corticosteroid prescribing in RA patients remains substantial and persists beyond 6 months once initiated. Rheumatologists need to determine causes and develop strategies to reduce corticosteroid use to minimise adverse event occurrence.

show abstract

“…The mechanisms for the higher observed prevalence of comorbidities in UC patients are beyond the scope of this study but may be associated with corticosteroids’ side effects. For example, a study of six inflammatory diseases (including 25,162 patients with inflammatory bowel disease) found that cumulative dose of oral glucocorticoids was associated with increased incidence of hypertension [ 29 ]; another study of patients with rheumatoid arthritis found that daily dose of ≥ 7.5 mg of glucocorticoids was associated with a hazard ratio of 2.33 (95% CI 1.68–3.22) for incident diabetes compared with patients not prescribed oral glucocorticoids [ 30 ]. Osteoporosis is also an important consideration for patients with increased dose and duration of corticosteroids exposure [ 31 , 32 ].…”

Section: Discussionmentioning

confidence: 99%

Understanding patient journey in ulcerative colitis prior to biologic initiation: a 5-year exploration

et al. 2021

View full text Add to dashboard Cite

Background There has been a more pronounced shift toward earlier, more aggressive therapies in Crohn’s disease than in ulcerative colitis (UC). The aim of this study was to describe the pre-biologic treatment and health care experience, including co-morbidities and overall health care utilization, for UC patients who initiated biologic therapies, in the 5 years prior to the initiation of the first biologic agent. Methods UC patients who initiated a biologic agent approved for UC between 9/15/2005 and 1/30/2018 were identified from the IBM® MarketScan® Commercial Database, a large US database. The date of the first recorded UC biologic exposure was defined as the index date, and ≥ 5 years of pre-index records were required to evaluate patients’ treatment, disease progression and overall health care utilization prior to initiating biologic agents. Results Among the 1891 eligible patients, treatment with oral corticosteroids, 5-aminosalicylates, and other non-biologic immunomodulators, all increased progressively across the 5 years prior to the index. From within year-five to within year-one prior to the index, the median duration of oral corticosteroid treatment increased from 34 to 88 days per year and the proportion of patients who experienced more extensive/pancolitis disease increased from 16 to 59%. Overall, the frequency of all-cause health care visits also increased. Conclusions Patients with UC experienced increasing morbidity and treatment burden in the 5 years prior to initiating biologic therapy. To achieve reduced corticosteroids in UC management, better risk stratification is needed to help identify patients for more timely biologic treatment.

show abstract

Oral glucocorticoids and incidence of hypertension in people with chronic inflammatory diseases: a population-based cohort study

Cited by 55 publications

References 24 publications

Dose-dependent oral glucocorticoid cardiovascular risks in people with immune-mediated inflammatory diseases: A population-based cohort study

Dose-dependent oral glucocorticoid cardiovascular risks in people with immune-mediated inflammatory diseases: A population-based cohort study

Changes in the pharmacological management of rheumatoid arthritis over two decades

Understanding patient journey in ulcerative colitis prior to biologic initiation: a 5-year exploration

Contact Info

Product

Resources

About