Small-dose, short-duration glucocorticoid use increases risk for cardiac events in RA
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SAN DIEGO — Glucocorticoid doses as small as 5 mg per day, in durations as short as 30 days, and a use period as long as 1 year all increase the risk for major adverse cardiac events in rheumatoid arthritis, said a speaker here.
“Up to half of RA patients in the United States use glucocorticoids despite previous evidence of increased odds of major adverse cardiovascular events,” Beth Wallace, MD, of the VA Ann Arbor, Michigan, and of the University of Michigan, told attendees at ACR Convergence 2023. “Ninety days of use may have a two-fold increase in risk.”
To assess the association between glucocorticoid use for RA and the risk for major adverse cardiovascular events (MACE), while also taking into consideration prior glucocorticoid exposure, Wallace and colleagues analyzed Veterans Affairs data for patients with an initial rheumatology visit between 2010 and 2018. The retrospective cohort study included patients aged older than 40 years and younger than 90 years, and excluded those with a non-RA rheumatologic condition, a history of MACE or chronic heart failure.
The researchers evaluated steroid use using a weighted cumulative dose estimate, with the weighted factors being glucocorticoid dose, duration and recency. Doses in the past were assigned as lower weight, while more recent doses are assigned at a higher weight, according to Wallace. The overall cohort included 18,882 patients with a mean age of 62.5 years. Approximately 84% were men. Baseline data showed that the median 5-year overall MACE risk was 5.3%, while 19.9% had a high risk for this outcome.
In all, 66% of the cohort received steroids during the study period. No glucocorticoid use was reported in 6,987 patients, while 7,158 patients used less than 1.2 mg per day and 4,737 used more.
According to Wallace, patients who received more than 1.2 mg per day on average demonstrated more than twice the risk for MACE than those who did not. Meanwhile, patients who used 5 mg of a prednisone equivalent for 90 days prior to MACE carried a 13% increase in risk for these events (aHR = 1.13; 95% CI, 1.01-1.24). This trend continued for patients receiving 7.5 mg equivalent (aHR = 1.19; 95% CI, 1.02-1.38) and a 10 mg equivalent (aHR = 1.27; 95% CI, 1.02-1.54) for 90 days before MACE.
Those who used 5 mg per day for 15 days before MACE also were at risk (aHR = 1.03; 95% CI, 0.99-1.06), as were those who used that dose for 30 days before an event (aHR = 1.05; 95% CI, 0.99-1.11).
According to the researchers, glucocorticoid use for 90 days prior to MACE carried a 10% increased risk (aHR = 1.10; 95% CI, 1.05-1.15) for the 5 mg dose, 15% increased risk (aHR = 1.15; 95% CI, 1.08-1.23) for the 7.5 mg dose and 21% increased risk (aHR = 1.21; 95% CI, 1.11-1.32) for the 10 mg dose.
Among patients who last used steroids 1 year before MACE events, the increase in risk was 3% (aHR = 1.03; 95% CI, 1.02-1.05) for the 5 mg equivalent, 5% (aHR = 1.05; 95% CI, 1.03-1.07) for the 7.5 mg equivalent and 7% (aHR = 1.07; 95% CI, 1.04-1.10) for the 10 mg equivalent.
“For patients who continued use, we saw a dose-response relationship with both duration of use and daily use,” Wallace said. “For patients who stopped using glucocorticoids, results show very similar trends to current use estimates.”
Wallace stressed that rheumatologists should consider the long history of MACE risk for patients with RA using glucocorticoids.
“Our study adds to the literature that ongoing short-term and low-dose steroid use is associated with increase in MACE risk,” she concluded.
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Wallace B. Abstract 2430. Presented at: ACR Convergence 2023; Nov. 10-15, 2023; San Diego.
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