Steroid Over-Prescribing Persists in RA Save

Almost half of patients with rheumatoid arthritis (RA) in the UK receive glucocorticoids from primary care physicians, and of those who are prescribed glucocorticoids, more than half receive more than 10 mg a day.

In the 17-year study period from January 1992 to December 2009, 16,536 patients with RA were identified in a large U.K. database. Among these, 47% of patients were prescribed at least one oral glucocorticoid during the study period. Some 20% of the cohort had received a glucocorticoid prescription in the 12 months preceding their diagnosis and of these, over 86% were prescribed further glucocorticoids during the follow-up interval, according to Rachel J. Black, MBBS, of the University of Manchester, and colleagues.

The median dose of glucocorticoids were 7.5 mg per day (Interquartile range, IQR 5-15.3 mg) for the average dose; 5 mg/day (IQR 2.5-7.5 mg) for the lowest dose, and 15 mg/day (IQR 7.5-30 mg) for the highest dose, the researchers reported online in Arthritis Research & Therapy.

Glucocorticoids have been used for RA for more than 60 years, and are effective for easing the pain and swelling associated with the disease. However, these drugs are associated with many potentially serious adverse effects, and current guidelines recommend that they be used for the shortest possible time and at the lowest effective dose.

"In the general population, glucocorticoids account for 2.5% of all adverse drug reactions leading to hospital admission," Black and colleagues observed.

For those who had ever received a prescription for a glucocorticoid, 83% received a prednisolone-equivalent daily dose of 5 mg/day; 58% received more than 10 mg/day, 39% received more than 20 mg/day, and 18% received more than 30 mg/day.

Of 7,777 patients who received glucocorticoids during the entire follow-up interval, the median duration of time spent on glucocorticoids was 0.80 years (IQR 0.15-2.56). The median number of courses given during the follow-up interval was five (IQR 2-12), and the median duration of each course was 50 days.

In addition, the course of glucocorticoid treatment exceeded 3 months in 57% and 1 year in 13%.

The median cumulative time spent on glucocorticoids was 10 months, the authors noted. "This highlights that some patients are taking glucocorticoids for longer than recommended, placing them at increased risk of developing side effects," they observed.

Older patients were more likely to be given these drugs, the analysis found. Each additional decade of life was associated with a 17% increase in likelihood for glucocorticoid use (OR 1.17, 95% CI 1.14-1.20). Patients with inflammatory comorbidities of the lung were also more likely to receive glucocorticoids.

Of the total cohort, 37% were given injectable glucocorticoids, with methylprednisolone prescribed most frequently at 72%.

"Many general practitioners and rheumatologists may be surprised by the proportion of patients, the dosages prescribed, and the duration of use of glucocorticoids in primary care, highlighting the need to be aware of glucocorticoids in this setting in order to avoid excess exposure and associated side effects," wrote Black and colleagues.

"Given the variety of treatment options available for RA, it is important to consider the individual patient's specific comorbidities and risk of developing glucocorticoid side effects and introduce alternative therapies where appropriate."

The investigators used the Clinical Practice Research Datalink (CPRD) database containing electronic health records from registered general practices in the U.K. All patients with an RA code recorded in CPRD between January 1992 and December 2009 were identified. Glucocorticoids prescribed included prednisolone, cortisone, hydrocortisone, triamcinolone, methylprednisolone, dexamethasone, betamethasone, budesonide, and deflazacort.

The likelihood of a patient receiving a glucocorticoid prescription during follow-up was over three times greater if they were seen by a high glucocorticoid prescriber compared to a low glucocorticoid prescriber (OR 3.10, 95% CI 2.90-3.31).

Limitations to the study include the fact that only rheumatologists are allowed to prescribe biological RA therapies in the U.K., and these data are not captured by the CPRD database. Likewise, data on disease activity was inaccessible that could be important to better understand which patients received glucocorticoid prescriptions and why.

The authors reported no financial conflicts.

This article is brought to RheumNow by our friends at MedPage Today. It was originally published on January 10, 2016.