Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study

Abstract

ObjeCtiveTo determine the frequency of prescriptions for short term use of oral corticosteroids, and adverse events (sepsis, venous thromboembolism, fractures) associated with their use. DesignRetrospective cohort study and self controlled case series.setting Nationwide dataset of private insurance claims. PartiCiPantsAdults aged 18 to 64 years who were continuously enrolled from 2012 to 2014. Main OutCOMe MeasuresRates of short term use of oral corticosteroids defined as less than 30 days duration. Incidence rates of adverse events in corticosteroid users and non-users. Incidence rate ratios for adverse events within 30 day and 31-90 day risk periods after drug initiation. resultsOf 1 548 945 adults, 327 452 (21.1%) received at least one outpatient prescription for short term use of oral corticosteroids over the three year period. Use was more frequent among older patients, women, and white adults, with significant regional variation (all P<0.001). The most common indications for use were upper respiratory tract infections, spinal conditions, and allergies. Prescriptions were provided by a diverse range of specialties. Within 30 days of drug initiation, there was an increase in rates of sepsis (incidence rate ratio 5.30, 95% confidence interval 3.80 to 7.41), venous thromboembolism (3.33, 2.78 to 3.99), and fracture (1.87, 1.69 to 2.07), which diminished over the subsequent 31-90 days. The increased risk persisted at prednisone equivalent doses of less than 20 mg/day (incidence rate ratio 4.02 for sepsis, 3.61 for venous thromboembolism, and 1.83 for fracture; all P<0.001). COnClusiOnOne in five American adults in a commercially insured plan were given prescriptions for short term use of oral corticosteroids during a three year period, with an associated increased risk of adverse events. IntroductionCorticosteroids are powerful anti-inflammatory drugs that have been used to treat a variety of diseases for over seven decades, dating back to their introduction for rheumatoid arthritis in 1949. [1][2][3][4][5] A strong driver of corticosteroid use is the potent symptomatic relief they give many patients. Yet long term use of corticosteroids is generally avoided, given the risks of serious acute complications such as infection, venous thromboembolism, avascular necrosis, and fracture, as well as chronic diseases such as diabetes mellitus, hypertension, osteoporosis, and other features of iatrogenic Cushing's syndrome. [6][7][8][9][10][11][12][13][14][15][16][17][18] Indeed, corticosteroids are one of the most common reasons for admission to hospital for drug related adverse events, 19 and optimizing their long term use has been a major focus for clinical guidelines across diverse specialties for many years. [20][21][22][23][24][25][26] In contrast with long term use, however, the risk of complications from short term use is much less understood, and evidence is generally insufficient to guide clinicians. In the outpatient setting, brief courses of oral corticosteroids are often used to treat conditions wit...

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