Steroids for RA: The argument heats up again

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Steroids for RA: The argument heats up again



Oct 18, 2005



Janis

St Louis, MO and Rochester, MN - A group of researchers from the Mayo

Clinic propose in an editorial in the October 2005 issue of the

Journal of Rheumatology that, far from harming the cardiovascular

(CV) system, glucocorticoids (GCs) " might actually reduce the risk of

cardiovascular disease (CVD) in patients with [rheumatoid arthritis]

RA " by lowering the background level of inflammation [1].



Although GCs have been implicated in increased CVD risk in several

settings, Drs M III, Hilal Maradit-Kremers, and Sherine E

think that the situation in RA patients might be different.

They suggest that RA patients differ from the general population

because of their high level of inflammatory mediators and that

" antagonism of such mediators by GCs might lead to reduced risk of CVD. "

GCs linked to contradictory CV effects

This is an interesting proposal, since steroid exposure has been

suspected in the twofold increased risk of CVD in patients with RA,

and other traditional CV risk factors do not fully explain the high

rate of CV problems associated with RA. With the growing recognition

of the role of inflammation in CV damage, other effects of steroids

are attracting research attention. " Inflammation plays a fundamental

role in the pathogenesis of CVD in RA, " writes.

notes that 30% to 50% of RA patients in recent therapeutic

trials report having taken GCs and that rheumatologists commonly use

these drugs as " bridge therapy " while waiting for slow-acting DMARDs

(or insurance reimbursement) to kick in and as treatment for RA

flares. Despite decades of use, surprisingly little is known about

the long-term effects of GCs in RA patients, particularly with regard

to the cardiovascular system.

For example, GCs might worsen CVD risk by increasing lipid levels,

worsening glucose tolerance, increasing hypertension, or increasing

obesity. Conversely, GCs might reduce CVD risk by reducing systemic

inflammation. The fact that effective treatment of systemic

inflammation with DMARDs is associated with reduced CV mortality

suggests that the latter effect is important, says.

An intriguing finding from epidemiologic studies is that RA flares

might trigger CV events. et al point out that the risk of a CV

event is independent of the duration of RA and that the risk of

sudden CV death and silent myocardial infarction increases very early

in the RA disease process. " These associations between episodic

fluctuations in level of systemic inflammation and onset of

cardiovascular events suggest the possibility that using GCs to

control flares of disease activity may actually lower the risk of

cardiovascular events, " the authors write.

Obviously, the tangled relationship between GC exposure, RA,

cardiovascular risk factors, and CVD requires a lot more research.

Meanwhile, et al write, " [E]radication of inflammation in RA

appears important, not only for the joints, but also for the

longevity of the cardiovascular system. Use of GCs in early RA and

targeted use to treat flares continues to be reasonable and possibly

beneficial. However, limiting chronic exposure and employing careful

measures to prevent osteoporosis, infection, and other steroid-

induced sequelae are critical. "

In a second editorial in the same issue of the journal, Drs Liron

Caplan, S , and Frederick Wolfe advise a considerably

more cautious approach [2].

" Short-term outcomes are clearly improved with glucocorticoids.

Studies that employ a brief exposure to steroids and subsequent

tapering are similarly encouraging. In the small minority of patients

uncontrolled on traditional DMARDS in combination with biologics, a

regimen of limited steroid use probably still makes sense, " Caplan

(Washington University School of Medicine, St Louis, MO) tells

rheumawire.



Caplan predicts that as pharmacoepidemiologic techniques become more

powerful, evidence of toxicity at progressively lower levels of GC

exposure will emerge. He says that physicians should be aware of the

adverse effects associated with GCs and take practical steps to

prevent them.

" For example, " Caplan says, " Limit exposure, use prophylactic calcium

and vitamin D, and in patients with lung disease, consider

pneumococcal vaccine. It would not be unreasonable to systematically

monitor patients on steroids for the broad spectrum of adverse

outcomes attributed to their use. "

http://www.jointandbone.org/viewArticle.do?primaryKey=579157