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Say Goodbye to Methotrexate in PMR?
For decades, glucocorticoids (GCs) have formed the backbone of polymyalgia rheumatica (PMR) management.
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Peyrac et al. 211 GCA. Relapse in 52% at median 261 days (so 1st year). 83% on GCs at relapse, median dose 6.5mg pred. 36% relapse post-toc discontinuation, at median 133 days. 64% no relapse when toc stopped, at median 511 days @RheumNow #ACR24 Abstr#2652 https://t.co/NqtdDNGGoc https://t.co/mXD8x7O6Ww
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Richard Conway RichardPAConway ( View Tweet)
A#2648
PET for GCA
Delayed imaging at 180 min improve dx performance for pts on GCs
Optimal PET w/in 3 days of GC, most patients unable to do w/in that window
Delay has sensitivity 92% even on prednisone - may be good tool for pts unable to get early PET/CT
#ACR24 @RheumNow https://t.co/kxpNfRqkGN
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Eric Dein ericdeinmd ( View Tweet)
Important study in SLE: out of 590 pts with pericarditis, 20% had recurrence w/in 1 year
Higher in early dx, younger pts, higher dx activity, & pred exposure
Is prednisone risk confounding by indication? Or causative?
#ACR24 @RheumNow @andreafava Abstr#2372 https://t.co/Seyi4F6weY
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Mike Putman EBRheum ( View Tweet)
Depressing finding re:glucocorticoid discontinuation in SLE
No improvement over decades in rate of GC discontinuation; if anything, we start more GC than ever
@AliDuarteMD help me out here; why haven't we made more progress?
#ACR24 @RheumNow Abstr#2421 https://t.co/uzZATKPWVC
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Mike Putman EBRheum ( View Tweet)
Abstract 2503: Clofutriben (HSD-1 inhibitor) minimizes adrenal suppression. Adding clofutriben to prednisolone boosts ACTH & cortisol levels with fewer patients with suppressed morning cortisol (≤5.0 mg/dL) (34% vs 14%).
@RheumNow #ACR24 #GCTox
Akhil Sood MD AkhilSoodMD ( View Tweet)
Class V #Lupus Nephritis usually takes longer to treat. Stay the course if no contraindications and taper steroids! - Dr A Askanase #ACR24 LN Guidelines @RheumNow https://t.co/4BBuAWi2da
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TheDaoIndex KDAO2011 ( View Tweet)
Instead of just JAKi, why don't we look at all our RA meds and MACE risk
FAERS data & reporting odds ratios here: all the caveats of voluntary reporting, so don't put too much weight, but...
prednisone. Don't forget pred is really not great for MACE!
#ACR24 ABST1981 @RheumNow https://t.co/L9SlPZF2Jd
David Liew drdavidliew ( View Tweet)
Systemic polyarteritis nodosa looks creepily/scarily beautiful on PET/CT. Look at that Christmas tree!
but sensitivity can be affected by pred, & isn't great even without (48%).
By itself, a good rule in test, but not a good rule out test.
#ACR24 ABST1962 @MayoClinic @RheumNow https://t.co/y28J6VKja4
David Liew drdavidliew ( View Tweet)
Further evidence for risk of #MACE with cumulative GC use in RA
In a national cohort of pts with RA: ⬆️cumulative GC exposure associated with ⬆️odds of MACE, regardless of baseline MACE risk
Ab1719 #ACR24 @RheumNow https://t.co/RmxokfBXYX
Mrinalini Dey DrMiniDey ( View Tweet)
STAR trial of GC w/d in RA LDA
SEMIRA of GC w/d controlled RA on Toci
Very slight disease activity increase, but higher flares
No symptomatic adrenal insufficiency, but data of abnormal ACTH stim
No good evidence of steroid w/d symptoms
Beth Wallace
@RheumNow #ACR24 https://t.co/j6UPWlVNIu
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Eric Dein ericdeinmd ( View Tweet)
Great table re:side effects of even low dose steroids in RA
Likely generalizes to other diseases ie PMR, SLE
P in prednisone stands for poison!
#ACR24 @RheumNow https://t.co/0opDEtzm9E
Mike Putman EBRheum ( View Tweet)
How do we prevent SLE flares requiring steroids?
Petri:
Background medication!
HCQ adherence is key
-check WB levels to measure
EULAR recs early addition of immunosuppress/biols
“Taper quickly, withdraw slowly”
Come down quick, then slowly off
@RheumNow #ACR24 @jhrheumatology
Eric Dein ericdeinmd ( View Tweet)
How do you treat a flare of SLE with steroids?
@RheumNow #ACR24
Eric Dein ericdeinmd ( View Tweet)
Petri: 5 mg prednisone or less is our standard for lupus control
EULAR 23 recs - early addition of immunosuppressant and/or biologics instead to prevent steroids
@RheumNow
#ACR24 @jhrheumatology https://t.co/jhxEeboPu5
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Eric Dein ericdeinmd ( View Tweet)
Reset the bar for remission (off steroids)!! Session #17S19
3% higher risk of organ damage for each 1mg of pred
Remission possible in rheum with lower dose GC regimen and faster taper #GCStewardship
#ACR24 @RheumNow @BethIWallace
Jiha Lee JihaRheum ( View Tweet)
Petri on Steroids in SLE
Steroid-related organ damage presents later
- organ damage is higher in African-Americans
Dose response for prednisone and CVD risk
Each 1 mg prednisone = 3% increase risk in organ damage!
#ACR24 @jhrheumatology
@RheumNow https://t.co/00S1mxrXJp
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Eric Dein ericdeinmd ( View Tweet)
GILZ is a negative regulator of the GC receptor, a potential steroid sparer target.
Dr. Miceli et al identified an E3 ligase of GILZ "E3-X" where deficiency leads to ⬆️ GILZ & ⬇️ inflammation.
More studies needed but a promising steroid sparer option.
@Rheumnow #ACR24 abs1646 https://t.co/GuVMkgOTXT
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sheila RHEUMarampa ( View Tweet)
Infertility in women with RA 2x higher
Risk factors
- age
- disease activity
- use of NSAIDs
- use of pred >7.5mg/day
With T2T aiming for remission, fertility improves and becomes similar to the general population
#ACR24 @RheumNow ABST#1647 https://t.co/B2Tx4dju4Z
Jiha Lee JihaRheum ( View Tweet)
17S19 session on steroid free future
@LesleyJacksonMD @EBRheum @BritAdlerMD
Is a (near) steroid free future for RA, ANCA, Lupus
#ACR24 @RheumNow
Eric Dein ericdeinmd ( View Tweet)
