Rheumatoid arthritis

Steroid use in RA remains steady despite DMARDs

More work is needed to reduce the use of “potentially toxic” steroids in patients with rheumatoid arthritis, research from the British Society for Rheumatology (BSR) Annual Conference 2020 concludes.

An analysis of UK prescribing trends over the past two decades found that despite an increase in the use of disease-modifying anti-rheumatic drugs (DMARDs), overall prescribing of glucocorticoids remained steady in rheumatoid arthritis patients.

Study leader Professor Philip Conaghan, Director of the Leeds Institute of Rheumatic and Musculoskeletal Medicine, told the limbic that the past 20 years had seen the introduction of new therapies and improved ideas around tight control of inflammation. As a result, he said, you would hope to see prescribing of treatments such as steroids decline.

“You would especially want to see glucocorticoid use reduce quite substantially,” he said.

“It was disappointing to see that we haven’t really made a big impact in reducing steroid use and it probably falls to both secondary care and primary care doctors to keep an eye on this.”

The analysis, published online after the BSR conference in Glasgow was cancelled due to coronavirus, looked at DMARD, oral glucocorticoid and NSAID prescribing in more than 71,000 rheumatoid arthritis patients in a primary care database between 1998 and 2017.

Overall the incidence of rheumatoid arthritis fell until 2011 when it rose again following the introduction of incentives in the GP contract.

Long-term DMARD prescribing rose from 30.97% in 1998 to 49.28% in 2017 with the researchers pointing out the figure is likely higher as primary care data does not capture some of the newer biologic therapies.

By contrast there were only modest changes in long-term glucocorticoid use with a fall from 20.98% to 15.53% over the period. Its use rose in the non-rheumatoid arthritis population, the researchers said.

Long-term NSAID prescribing fell 45.94% to 25.08% among rheumatoid arthritis patients while increasing slightly in other groups (6.37% to 8.41%).

Professor Conaghan said one of the key messages was it was really hard to wean patients off steroids and it was an important reminder to not start them in new patients.

“Even with increased DMARD use we’re not seeing the expected reduction in therapies like steroids.

“We probably need to get better both as rheumatologists and in collaboration with primary care. You have people who have had 10 years or more of therapy so trying to wean them off is really hard. The big message is wherever possible we shouldn’t be starting people on steroids these days because once you start its difficult to get them off.”

“But the message remains clear – we still haven’t got rid of these baseline toxic drugs.”

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