June 24, 2019
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Steroid use in polymyalgia, GCA linked to significantly higher infection risk

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Mar Pujades-Rodriguez

The use of oral steroids in patients with polymyalgia rheumatica or giant cell arteritis is associated with a significant increase in the risk for infection, with higher doses linked with higher risks, according to recent findings published in the Canadian Medical Association Journal.

“Polymyalgia rheumatica and giant cell arteritis are two common rheumatological diseases of older people,” Mar Pujades-Rodriguez, PhD, MSc, of the University of Leeds in England, told Healio Rheumatology. “They are treated with medium-to-high doses of oral steroids — for example, up to 15 mg of prednisolone for polymyalgia rheumatica and up to 60 mg for giant cell arteritis — for 6 months to several years. Steroids are effective in reducing inflammation and disease symptoms, but they also reduce the ability of the immune system to fight infections.”

She added, “Doctors and scientists know that steroids increase the risk of infection, but no one has successfully quantified this risk in a way that is useful to patients, clinicians and decision makers.”

 
The use of oral steroids in patients with polymyalgia rheumatica or GCA is associated with a significant increase in the risk for infection, according to recent findings.
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To analyze the dose-response risk for infection among patients in England with polymyalgia rheumatica or giant cell arteritis, Pujades-Rodriguez and colleagues conducted a retrospective record-linkage study of adults seen at family practices that participate in the Clinical Research Datalink. Specifically, patients with prevalent and incident polymyalgia rheumatica or giant cell arteritis who consented to data linkage to hospital databases, and who were registered in their family practice in England for at least 1 year between Jan. 1, 1997, and March 15, 2017, were included in the study.

The researchers analyzed data on 39,938 patients from 389 family practices. The researchers obtained estimates of first occurring infection per level of time-variant current and cumulative steroid dose using Kaplan-Meier methods, as well as multilevel, proportional-hazards Cox models. The primary outcome was the first occurrence of all-cause infection.

According to the researchers, 55.7% of included patients experienced at least one infection over a median follow-up period of 4.8 years, with 26.7% requiring hospital admission and 7.3% dying within 7 days of diagnosis. The cumulative risks for all-cause infection were 18.3% (95% CI, 17.9-18.7) at 1 year, 54.7% (95% CI, 54.1-55.2) at 5 years and 76.9% (95% CI, 76.2-77.5) at 10 years.

The most common cases were lower respiratory tract infections, conjunctivitis and herpes zoster.

The adjusted HR for all-cause infection per increase in 5-mg prednisolone equivalent daily dose was 1.13 (95% CI, 1.12-1.14). For 1,000-mg cumulative dose increases in the last year from the end of follow-up, the increase was 1.5 (95% CI, 1.49-1.52). In addition, the researchers noted stepwise dose-related links for bacterial, viral, parasitic and fungal infections, regardless of patient age, duration of underlying chronic disease and baseline vaccination status.

“Patients with polymyalgia rheumatica and giant cell arteritis and clinicians should be educated about the risk of infection, need for symptom identification, prompt treatment, timely vaccination and documentation of history of chronic infections, such as herpes zoster,” Pujades-Rodriguez said.

“The management of infections has major cost and workload implications for the health care system,” she added. “The estimated risks of dose-response associated with steroids can be useful for clinicians and policymakers to guide the introduction of alternative drugs and improve outcomes of patients with these rheumatological diseases. For example, conducting benefit-harm assessments of newly licensed steroid-sparing drugs that could be recommended instead of oral steroids.” – by Jason Laday

Disclosures: Pujades-Rodriguez reports no relevant financial disclosures. Please see the full study for additional researchers’ disclosures.