Prednisone for 1 month or longer a key predictor of osteonecrosis in lupus
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Prednisone in doses of 20 to 39 mg for more than 1 month, or 40 mg daily for just 1 month, remains the most important corticosteroid predictor of osteonecrosis in patients with systemic lupus erythematosus, according to data.
“Osteonecrosis (ON) remains a serious complication in systemic lupus erythematosus (SLE) with prevalence ranging from 10% to 50%,” Romy Kallas, MD, of Johns Hopkins University School of Medicine, and colleagues wrote in Arthritis Care & Research. “The prevalence of asymptomatic ON has been estimated at 40%.”
“The increased incidence of ON in SLE patients compared to the general population, other autoimmune diseases, or other diseases requiring high doses of corticosteroids, suggested the presence of SLE specific risk factors,” they added. “Over the years, multiple studies have evaluated predictors of ON. Of the known risk factors, glucocorticoid use remains the most important one. Whether the risk of ON is increased by the duration of corticosteroid treatment, initial dose during the first 3 months, the highest daily dose, continuous high dose, mean or cumulative dose remains undetermined.”
To analyze the predictors of osteonecrosis — particularly the role of prednisone dose and duration — among patients with SLE, Kallas and colleagues examined data from the Johns Hopkins Lupus Cohort. Established in 1987, this longitudinal cohort includes patients diagnosed with SLE at John Hopkins Hospital, with comprehensive medical history, including year of diagnosis, and clinical and laboratory information obtained at entry. In all, the researchers analyzed data from 2,428 patients with SLE, representing 224,295 person‐months of follow‐up.
Kallas and colleagues used pooled logistic regression to assess the relationship between risk factors and rates of osteonecrosis. After identifying a set of variables related to osteonecrosis incidence, they then fit a final multivariable model to identify the most important risk factors for incident osteonecrosis.
According to the researchers, 122 incident osteonecrosis events were recorded during 18,691 person‐years of follow up. In the multivariable analysis, African American patients demonstrated twice the risk for osteonecrosis compared to white patients. In addition, men had an 80% increased risk for osteonecrosis compared to women, while smokers had a 50% increased risk compared with non-smokers. Meanwhile, for every 10-year increase in the age at diagnosis, there was a 20% reduced risk for osteonecrosis. Patients diagnosed after the 1990s also demonstrated a 50% reduced risk for osteonecrosis, compared with those diagnosed prior to that decade.
Regarding prednisone, daily doses of 20 to 39 mg or higher, when administered for more than 1 month, significantly increased the risk for osteonecrosis. This significant, increased risk was also seen with daily doses of prednisone 40 mg, even when administered for just 1 month. The use of pulse methylprednisolone or intramuscular triamcinolone was not associated with an increased risk for osteonecrosis.
“A dose of 20 to 39 mg daily of prednisone for more than a month at any point during the disease was a predictor of ON,” Kallas and colleagues wrote. “Prednisone at 40 mg for just one month was an even stronger predictor. More conservative use of oral prednisone use, even in lupus nephritis, is now possible. The Rituxilup pilot study and the more recent voclosporin trial have demonstrated that oral steroids can be safely limited even in patients with lupus nephritis.”
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