Use of corticosteroids in patients with rheumatoid arthritis treated with infliximab: treatment implications based on a real-world Canadian population

Abstract

ObjectiveTo describe the rate of concomitant oral corticosteroid use at antitumour necrosis factor (TNF) initiation and at disease remission, and to assess its effect on incidence of infection and sustainability of remission among patients with rheumatoid arthritis (RA) treated with infliximab in Canadian routine care.MethodsBiological naïve patients with RA followed in the Biologic Treatment Registry Across Canada (BioTRAC) were included. The time-dependent association between corticosteroid dose (no use, ≤5 mg/day, >5 mg/day) and the incidence of first infection, while considering possible confounders, remission sustainability and the incidence of subsequent infections were assessed with Cox regression.Results838 patients were included; mean (SD) baseline age and disease duration were 55.6 (13.5) and 10.5 (9.8) years, respectively. After a mean (SD) of 51.3 (43.6) months, the total incidence of adverse events (AEs) and infections were 110.2 and 19.6 per 100 person-years (PY), respectively. In multivariate analysis, the HR (95% CI) for acquiring an infection was 2.48 (1.24 to 4.98) with >5 mg/day of corticosteroids versus no corticosteroids. Similarly, ≤5 mg/day of corticosteroids was associated with increased hazard for infection (2.12 (0.97 to 4.66)). Despite DAS28 (disease activity score 28) or Clinical Disease Activity Index (CDAI) remission, corticosteroids were continued in 16.4% and 16.7% of cases, respectively. Continued corticosteroid treatment was not associated with sustainability of remission (HRDAS28 (95% CI) 1.40 (0.95 to 2.06); HRCDAI 1.19 (0.75 to 1.88)), however, it had a significant impact on development of infection (HRDAS28 (95% CI) 1.78 (1.00 to 3.19); HRCDAI 2.38 (1.14 to 4.99)).ConclusionsOral corticosteroid treatment was associated with increased risk of development of infection without impacting sustainability of remission. These results support the notion that corticosteroids should be used concomitantly with anti-TNF for the shortest period possible to achieve remission, and then tapered.Trial registration numberNCT00741793.

A Retrospective Analysis of Corticosteroid Utilization Before Initiation of Biologic DMARDs Among Patients with Rheumatoid Arthritis in the United States

“…Moreover, the literature is by no means consistent concerning low-dose corticosteroids and their association with adverse events. For example, Haraoui et al found that, compared to non-corticosteroid users, risk of infection was significantly increased among RA patients who used corticosteroids at either lower doses (B 5 mg) or higher doses ([5 mg) [33]. As such, there are challenges in understanding the nuances of how corticosteroid dosage may impact adverse events.…”

Association of weight loss with improved disease activity in patients with rheumatoid arthritis: A retrospective analysis using electronic medical record data

“…We used t -tests for continuous normally distributed variables, Wilcoxon rank-sum tests for continuous non-normally distributed variables, chi-square tests for categorical variables, and Fisher’s exact tests for categorical variables with small cell sizes. We evaluated these covariates as possible confounders due to their associations with RA disease activity in prior literature (23–27). …”

Acute Respiratory Events in Connective Tissue Disorders

“…Coadministration of biological factors or a combination of these therapies with high doses of corticosteroids multiplies the risk of infection and should definitively be avoided, especially in elderly patients with lung comorbidities. On the other hand, upon a developed lung infection, discontinuation of immunosuppression does not lead to precipitous reconstitution of the immune system [55,65,66,67,68,69,70,71]. All the above parameters significantly increase the risk of bacterial, mycobacterial, viral, and fungal pulmonary infections in CTD patients (fig.…”

“…Corticosteroids, for example, suppress both humoral and cellular immunity and have been shown to increase the infection rate by a factor of 2-4 at any dose, with doses of more than 20 mg prednisone per day having the most deleterious effect [54,65]. The rest of the disease-modifying drugs, both synthetic and biological, are also implicated in the increased risk of common, mycobacterial, and opportunistic infections.…”