Short-term glucocorticoid use increases the risk of MACE

In a US cohort of patients with rheumatoid arthritis (RA), long-term use of glucocorticoids (GCs) was common, with 1 in 6 participants using GCs for >90 days in a 6-month period. Ongoing use was associated with a dose- and duration-dependent risk of major adverse cardiovascular events (MACE), even at doses of 5 mg and a duration of 15–30 days. Notably, prior GC use up to 1 year before risk assessment may remain associated with an increased risk of MACE.

The results were presented by Dr Beth Wallace (University of Michigan, MI, USA) [1]. Her group's recent work suggested that 1–13 days of GC use in the past 6 months is associated with a 63% increase in the risk of MACE, and ≥90 days with a 220% increase [2]. However, this study did not adequately consider the effect of prior GC exposure and dose on current risk.

Wallace's group performed a retrospective national cohort study that included RA patients with at least 1 visit to a rheumatology clinic from 2010 to 2018. Exclusion criteria were age <40 or >90, other rheumatologic disease, prior MACE, or congestive heart failure (CHF).

Wallace and colleagues estimated the effect of time-varying cumulative weighted oral GC use on the risk of MACE. They focused on 4 clinically meaningful exposure patterns: GC use of 15, 30, 90, and 180 days, both in patients with ongoing GC use at the time of MACE and use that ended before MACE.

The study cohort included 18,882 patients with a mean age of 62.5 years, of which 84% were male. A total of 6,987 patients (34%) had never used GCs, 7,158 had used ≤1,2 mg/day, and 4,737 had used >1.2 mg/day. The median 5-year MACE risk at baseline was 5.3%. Of note, 3,754 patients (19.9%) had a high baseline MACE risk.

Incident MACE occurred in 4.1% of patients, with a median time to MACE of 2.67 years. There was a dose-response relationship between MACE and GC use. For example, in patients with ongoing GC use, 5 mg/day for 30 or 90 days increased MACE risk by 5% (HR 1.05; 95% CI 0.98–1.10) and 10% (HR 1.10; 95% CI 0.97–1.21), respectively. Weighted estimates for patients who stopped steroids before MACE showed very similar trends, with slightly smaller effect sizes. For example, in patients who had ended GC use 1 year before MACE, 5 mg/day for 30 or 90 days increased MACE risk by 3% (HR 1.03; 95% CI 1.01–1.04) and 9% (HR 1.09; 95% CI 1.04–1.14), respectively.

The results suggest that prior GC use has a larger impact on MACE risk than previously identified, Dr Wallace commented. She added that the model needs to be externally validated and that among other factors, steroid exposure >2 years ago needs to be accounted for.

1. Wallace B, et al. Time-dependent evaluation of weighted cumulative glucocorticoid exposure and major adverse cardiovascular events in a cohort of veterans with rheumatoid arthritis. 2430, ACR Convergence 2023, 10–15 November, San Diego, USA.
2. Wallace B, et al. 2219, ACR Convergence 2022, 10–14 November, Philadelphia, USA.

Medical writing support was provided by Michiel Tent.
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Posted on 1 December 20231 December 2023