Considering the state of glucocorticoid use in RA
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In November 2020, the American College of Rheumatology unveiled updated treatment guidelines that emphasized consideration of other therapies before glucocorticoids for rheumatoid arthritis.
The availability of novel therapies and concerns about adverse effects have also relegated glucocorticoids to the background. However, because they have long been a mainstay of treatment for RA, this shift away from glucocorticoid use raised questions about where they now fit among therapeutic options for RA.
In an email interview with Healio, Elizabeth Volkmann, MD, MS, assistant professor of medicine, director of the UCLA Scleroderma Program and co-director of the CTD-ILD Program in the division of rheumatology at the University of California, Los Angeles, discussed how glucocorticoids are often used in clinical practice, how to approach tapering off glucocorticoids and considerations for use of glucocorticoids while being mindful of the ACR guidelines.
Healio: How often are glucocorticoids currently prescribed for patients with RA?
Volkmann: Glucocorticoids are often prescribed for patients newly diagnosed with RA in parallel with disease-modifying therapy, as well as for patients experiencing RA flares.
Healio: Given the novel therapeutic options, where do glucocorticoids fit into the current treatment landscape?
Volkmann: Due to safety concerns, long-term use of glucocorticoids is not recommended, particularly at moderate-to-high dosage levels. However, there is some evidence that low-dose glucocorticoids may possess disease-modifying effects in RA. Further, as the [SEMIRA study] demonstrated, low-dose glucocorticoid therapy may be safe to use, at least in the short-term.
Healio: Recently updated ACR guidelines represent a push to consider other therapies before prescribing glucocorticoids, even for bridge therapy. Are the updated guidelines a manifestation of an existing theme or are they a true driver for a change in practice?
Volkmann: This is a challenging and complex issue. Glucocorticoids are relatively inexpensive and widely available, which makes them an attractive bridge therapy for many providers, particularly for those who practice in areas where biologic therapies are less readily available. While the updated guidelines represent a step forward in this field, they have to be considered in the context of the real-world experience of RA care and treatment.
Healio: What are the major concerns regarding glucocorticoid use in patients with RA?
Volkmann: Long-term use of glucocorticoids is associated with an increased risk for diverse adverse health outcomes, including osteoporosis, coronary artery disease, cataracts, weight gain, diabetes and muscle atrophy.
Healio: Tapering off glucocorticoids is viewed as beneficial. Considering a paucity of research, how would you advise rheumatologists to approach tapering?
Volkmann: I recommend applying a personalized, patient-centered strategy to tapering off of glucocorticoids. While patients are tapering, they need to be followed closely, not only to assess disease activity but also to monitor for the development of adrenal insufficiency, particularly if they have a long-standing history of glucocorticoid therapy use. There is no one tapering strategy that can be universally applied to every patient; however, every patient will benefit from tapering under the supervision of a provider who listens to their complaints and performs a careful and comprehensive history and physical examination.
Healio: In the COVID-19 era, is there concern about the use of glucocorticoids because they are immunosuppressants?
Volkmann: This is an evolving area of research, and currently there is no consensus on the dosage of glucocorticoids that would increase a patient’s risk for COVID-19-related complications.
References:
For more information:
Elizabeth Volkmann, MD, MS, can be reached at evolkmann@mednet.ucla.edu.
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