Despite several studies reporting the severe adverse events associated with chronic glucocorticoid use, they are still prescribed as the mainstay of treatment in routine practice to reduce inflammation and disease activity. The 2019 European League Against Rheumatism (EULAR) recommendations have also strongly advocated tapering glucocorticoids to the lowest possible dose for the effective management of RA. According to an original research study published in RMD, open, tapering doses of glucocorticoids >2.5 mg/day helps in minimizing the risk of flare, whereas the risk was higher in those who had tapering ≤2.5 mg/day.
The case-crossover study conducted by Adami et al. involved 508 patients with RA, among these 267 had at least one episode of flare. The researchers observed the highest risk of flare in subjects who discontinued bDMARDs and tapered 0-2.5 mg/day (adjusted odds ratio (AOR) of 1.45, 95% CI: 1.13 to 2.24 and aOR of 1.37; 95% CI: 1.06 to 2.01, respectively). However, no significant increase in flare risk was noted upon tapering the dose to >2.5 mg/day, despite the use of a different definition of flare.
Around 50% of the patients with early RA are advised to discontinue glucocorticoids in 3 years of treatment, but episodes of flare have been observed in 30% of the subjects within the next 6 months of discontinuation. The currently used tapering strategies for the management of RA are largely based on clinicians’ experience and the ideal dosage to prevent flare is largely unknown. The findings of the Steroid EliMination In Rheumatoid Arthritis (SEMIRA) trial published in 2020 Lancet have found that continuing glucocorticoids at 5 mg per day for 24 weeks was superior to tapering in achieving safe and better disease control in patients who attained low disease activity with tocilizumab and at least 24 weeks of glucocorticoid treatment.
Further studies may help in designing newer tapering strategies and developing clear consensus on the optimal dosage for tapering glucocorticoids in the RA population.
References
- Hua C, Buttgereit F, Combe BGlucocorticoids in rheumatoid arthritis: current status and future studiesRMD Open 2020;6:e000536.
- Burmester GR, Buttgereit F, Bernasconi C, Álvaro-Gracia JM, Castro N, Dougados M, Gabay C, van Laar JM, Nebesky JM, Pethoe-Schramm A, Salvarani C, Donath MY, John MR; SEMIRA collaborators. Continuing versus tapering glucocorticoids after the achievement of low disease activity or remission in rheumatoid arthritis (SEMIRA): a double-blind, multicentre, randomized controlled trial. Lancet. 2020 Jul 25;396(10246):267-276.