George et al. sought to evaluate the risk of serious infection associated with low-dose glucocorticoids by identifying more than 120,000 patients with RA who had been on stable immunotherapy for longer than six months and who were receiving no glucocorticoids or less than 5 mg per day. The researchers found that patients treated with glucocorticoids at doses of <5 mg/day had a statistically significant higher risk of hospitalized infection than patients who did not receive glucocorticoids.3
These and other study results highlight potential safety concerns with glucocorticoids, while the results of other studies present insights into the potential efficacy of low-dose glucocorticoids. In the SEMIRA trial, 259 patients with RA who were receiving tocilizumab and 5–15 mg/day of glucocorticoids for 24 weeks and who demonstrated stable, low disease activity were randomized to either continue masked prednisone at a dose of 5 mg daily for 24 weeks or to taper masked prednisone, reaching 0 mg per day at week 16.
In this study, Burmester et al. found that continuing glucocorticoids at 5 mg per day for 24 weeks provided better disease control than tapering glucocorticoids, but they also found that 65% of patients in the glucocorticoid-tapering arm remained in low disease activity.4
Thus, Dr. England explained, clinicians must work with patients to weigh the risks and benefits of using and tapering glucocorticoids to treat rheumatoid arthritis.
Therapy Modification
Several rules of thumb should be applied when considering treatment modifications. Dr. England explained: 1) treat-to-target is an important and evidence-based strategy, 2) numerous alternative treatments to methotrexate monotherapy exist—including triple therapy—and selection of these regimens should be tailored to the patient; 3) continuing methotrexate with most biologics is generally recommended; and 4) Janus kinase inhibitors can be an effective treatment for many patients, but the U.S. Food & Drug Administration’s Boxed Warning regarding major adverse cardiovascular events, malignancy, thrombosis and mortality requires consideration.
When contemplating tapering DMARD therapy for patients, Dr. England stated that flares will likely occur, and patients must be monitored and restarted on effective therapies in such circumstances. In general, a dose-reduction tapering strategy is less likely to cause disease flares than tapering off completely or abruptly discontinuing therapy.
In Sum
Dr. England’s talk was comprehensive and well researched, and thanks to this lecture, audience members can now feel more comfortable staying up to date on a disease that is seen in the clinic nearly every day.
