Reconsidering Steroids Save

There is not a single one of us in rheumatology who hasn’t prescribed steroids, but we really need to reconsider how much and how often we use them. In almost every disease state we treat, we are seeing progression towards lesser and shorter courses. Whether it’s ANCA-vasculitis and the PEXIVAS study showing efficacy of reduced dose steroid course or the GIACTA trial in giant cell arteritis proving efficacy of a more rapid taper of steroids alongside tocilizumab. Even this year’s great debate at the ACR was centered around the use of biologics as first line treatment of polymyalgia rheumatica and giant cell arteritis. Why? One of the major reasons was to decrease the patient’s steroid burden. 

Another abstract (2430) this year focused on steroid exposure and its association with major adverse cardiovascular events in rheumatoid arthritis. This was a large retrospective cohort study, using the national veterans association’s database looking at RA patients from 2010 to 2018. Notably these patients did not have any prior MACE or congestive heart failure diagnosis. 

In total, there were over 18,000 patients identified with an incidence of MACE events of 4.1%. Not surprisingly, steroid use was associated with increased MACE incidence. Using 5mg, 7.5mg, 10mg daily of prednisone for 90 days prior MACE was associated with a 13%, 19% and 27% increase in MACE. Similar doses of prednisone even for just 30 days, with last use one year prior to MACE was associated with 3%, 5% and 7% increases in MACE. 

Overall, this study showed a dose, duration and recency dependence relationship between steroid use and MACE. However the take home message is that even a low dose of 5mg of prednisone for as short as 30 days and as long as one year prior to MACE were associated with an increased risk of MACE. 

We often think and convince ourselves that 5mg of prednisone is physiologic and some of us even get more comfortable when doses are 5mg or below because of this. However, this data should make us think twice. We should continue to be diligent and persistent with our steroid tapers, and we should not “settle” until prednisone reaches 0mg daily. Once we begin steroids, our immediate next step should focus on when we can start tapering. Lastly, this steroid data should make us think about starting steroid sparing therapies earlier in the treatment course and perhaps even in conditions where we aren’t traditionally adept in using steroid sparing treatments immediately such as polymyalgia rheumatica and giant cell arthritis.