Fewer RA patients starting steroids and more patients stopping 

Oral glucocorticoid use in patients with rheumatoid arthritis is coming down over time, according to Australian registry data.

However the study of 3,699 patients in the Australian Rheumatology Association Database (ARAD) failed to show that biologics had a significant glucocorticoid sparing effect.

Instead, the findings may reflect an increasing awareness of the adverse effects associated with glucocorticoids as well as ‘increased availability of effective disease modifying agents’.

Dr Rachel Blake, a consultant rheumatologist at the Royal Adelaide Hospital, told the limbic that fewer patients were commencing on glucocorticoids and more patients who were already taking the drugs were coming off them.

Overall, glucocorticoid use dropped from 55% between 2001 and 2005 to 39% between 2012 and 2015.

However she warned it can be hard to wean some patients off the drugs.

“By doing the transition state analysis, where we looked at patients starting and stopping oral glucocorticoids, we were able to show clinicians were less likely to start patients on them. But once patients were on glucocorticoids, we weren’t able to get them off.”

She said this was particularly the case for elderly patients.

“We don’t really have a good answer as to why we are unable to get them off.  Is it physiological? Is it patient perception?”

“Often you’ve got comorbidities and perhaps the glucocorticoids are helping with those symptoms as well as joint symptoms, and patients feel they are doing better on steroids.”

She said anecdotally, patients would sometimes claim their steroids were helping even non-inflammatory symptoms such as osteoarthritis.

The study concluded clinicians should consider intramuscular and intra-articular administration of glucocorticoids to offset oral use.

“You might use an intra-articular injection for the person who has otherwise responded quite well to their disease modifying treatment but they have one really resistant or sticky joint that is persistently troubling them.”

While there was evidence of clinical effectiveness for the injections and an expectation that less systemic absorption would translate into fewer adverse effects, Dr Black said the area was unfortunately a ‘research free zone’.

“It seems like we are going in the right direction with rheumatoid arthritis where we do have the option of using other medications besides glucocorticoids. We are stopping them more frequently and starting them less frequently which is a really positive message given we know there are so many adverse effects that can have a really big impact on patients.

She added clinicians should always be looking for circumstances to stop the drugs particularly in the elderly due to the risk of interactions with comorbidities and other medications.

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