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Certain perspectives about the use of corticosteroids for managing hospitalized patients with rheumatic diseases

  • Perspectives in Rheumatology
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Abstract

The administration of cortisone to a bedridden patient with rheumatoid arthritis (RA) 70 years ago was a transformative event in modern medicine. We have since struggled to balance the near-miraculous anti-rheumatic with the yet all-too-frequent devastating side effects of glucocorticoids (GC). With the current availability of newer disease-modifying and biologic anti-rheumatic agents, we were rather surprised to note that 94% of sick hospitalized patients with systemic rheumatic diseases at our medical center were on corticosteroids during a 3-month observation period. Comparing contemporary with past practices from historical references, we confirmed a perhaps paradoxical trend of increasing steroid usage in certain contexts over the years. Sixty-seven percent of our hospitalized lupus patients were started on GC of greater than 30 mg prednisone equivalent compared with 50% in the 1950s. Seventy-five percent of our RA inpatients had their GC dose increased on discharge. Both (2/2) our new RA patients were started on GC, compared with 69% in the 2000s and just 36% in the 1990s. This likely reflects both improved abilities to keep sick patients alive and inability of other anti-rheumatic therapies to consistently induce or sustain disease remission compared with the usually highly efficacious yet inexpensive GC in these particular patients. Administration of glucocorticoids to ill, often infected, patients with systemic rheumatic diseases remains more art than science. Current perspectives view glucocorticoids as considerably less salutary than previously thought; we are still challenged to keep our patients from developing preventable complications. These observations emphasize the need for more and better therapeutic alternatives to glucocorticoids. There are now several examples—disease-modifying and biologic medications for RA and biologics for lupus and vasculitis—that suggest the possibility of caring for our patients without the historical reliance on corticosteroids. We have made enormous progress since steroids were first offered to a patient with RA in 1948. We are hopeful the future will bring us interventions of comparable or better efficacy that are safer.

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References

  1. Kelly A, Panush RS (2017) Diagnostic uncertainty and epistemologic humility. Clin Rheum 36(6):1211–1214

    Article  Google Scholar 

  2. Makol A, Davis JM 3rd, Crowson CS, Therneau TM, Gabriel SE, Matteson EL (2014) Time trends in glucocorticoid use in rheumatoid arthritis: results from a population-based inception cohort, 1980-1994 versus 1995-2007. Arthritis Care Res 66(10):1482–1488

    Article  Google Scholar 

  3. Albert DA, Hadler NM, Ropes MW (1979) Does corticosteroid therapy affect the survival of patients with systemic lupus erythematosus? Arthritis Rheum 22(9):945–953

    Article  CAS  Google Scholar 

  4. Hunder GG, Matteson EL (2010) Rheumatology practice at Mayo Clinic: the first 40 years–1920 to 1960. Mayo Clin Proc 85(4):e17–e30

    Article  Google Scholar 

  5. Burmester GR, Bijlsma JWJ, Cutolo M, McInnes IB (2017) Managing rheumatic and musculoskeletal diseases—past, present and future. Nature Rev Rheum 13(7):443–448

    Article  CAS  Google Scholar 

  6. McCarty DJ (1984) Crystal deposition diseases. In: McCarty DJM (ed) Landmark advances in rheumatology. Contact Associates International Ltd., Atlanta, GA, pp 73–88

    Google Scholar 

  7. Tan M (1984) The LE cell and antinuclear antibodies: a breakthrough in diagnosis. In: McCarty DJM (ed) Landmark advances in rheumatology. Contact Associates International Ltd., Atlanta, GA, pp 43–52

  8. Dubois EL (1956) Systemic lupus erythematosus: recent advances in its diagnosis and treatment. Ann Intern Med 45(2):163–184

    Article  CAS  Google Scholar 

  9. Mannik M (1984) Rheumatoid factors—their discovery and possible role in pathogenesis of rheumatoid arthritis. In: McCarty DJ (ed) Landmark advances in rheumatology. Contact Associates International Ltd., Atlanta, GA, pp 103–110

  10. Seegmiller JE (1984) Conquest of gouty arthritis. In: McCarty DJ (ed) Landmark advances in rheumatology. Contact Associates International. Ltd, Atlanta, GA, pp 89–102

    Google Scholar 

  11. Fauci AS, Katz P, Haynes BF, Wolff SM (1979) Cyclophosphamide therapy of severe systemic necrotizing vasculitis. New Engl J Med. 301(5):235–238

    Article  CAS  Google Scholar 

  12. Weinblatt ME (2009) Methotrexate: personal reflections. In: Pisetsky DS (ed) The ACR at 75 a diamond jubilee. John Wiley & Sons, Inc, Hoboken, pp 157–160

  13. Burns CM (2016) The history of cortisone discovery and development. Rheum Dis Clin 42(1):1–14 vii

    Article  Google Scholar 

  14. Hillier SG (2007) Diamonds are forever: the cortisone legacy. J Endocrinol 195(1):1–6

    Article  CAS  Google Scholar 

  15. Pensabeni-Jasper T, Panush RS (1996) Review: corticosteroid usage: observations at a community hospital. Amrt J Med Sci 311(5):234–239

    Article  CAS  Google Scholar 

  16. Cohen H, Bywaters EGL, Copeman WSC, Dodds C, Duthie JJR, Bradford Hill A et al (1954) A comparison of cortisone and aspirin in the treatment of early cases of rheumatoid arthritis; a report by the Joint Committee of the Medical Research Council and Nuffield Foundation on clinical trials of cortisone, A.C.T.H., and other therapeutic measures in chronic rheumatic diseases. Brit Med J 1(4873):1223–1227

    Article  Google Scholar 

  17. Bywaters EGL, Copeman WSC, Duthie JJR, Fletcher ETD, Dudley Hart F, Kersley GD et al (1955) Empire Rheumatism Council. Cortisone/aspirin trial: multi-centre controlled trial comparing cortisone acetate and acetyl salicylic acid in the long-term treatment of rheumatoid arthritis. Ann Rheum Dis 14(4):353–370

    Article  Google Scholar 

  18. Cohen H, Bywaters EGL, Copeman WSC, Dodds C, Duthie JJR, Bradford Hill A et al (1960) A comparison of prednisolone with aspirin or other analgesics in the treatment of rheumatoid arthritis: Medical Research Council and Nuffield Foundation report. Ann Rheum Dis 19(4):331–337

    Article  Google Scholar 

  19. Brody JE. Hailed and feared cortisone now safer and more varied. The New York Times 1981. http://www.nytimes.com/1981/01/20/science/hatiled-and-feared-cortisone-now- safer-and-more-varied.html?pagewanted=all

  20. Neeck G (2002) Fifty years of experience with cortisone therapy in the study and treatment of rheumatoid arthritis. Ann N Y Acad Sci 966(1):28–38

    Article  CAS  Google Scholar 

  21. (1956) Cortisone versus Aspirin. The Lancet 267(6916):325–326

  22. Wijdicks EFM, Rooke TW, Hunder GG, Dacy MD (2019) Cortisone in popular culture: Roueché, Ray, and Hench. Mayo Clin Proc 3(2):215–220

    Google Scholar 

  23. Homburger F, Bonner CD (1979) The treatment of Raoul Dufy's arthritis. New Engl J Med. 301(12):669–673

    Article  CAS  Google Scholar 

  24. Petri M, Purvey S, Fang H, Magder LS (2012) Predictors of organ damage in systemic lupus erythematosus: the Hopkins Lupus cohort. Arthritis Rheum 64(12):4021–4028

    Article  CAS  Google Scholar 

  25. Overman RA, Yeh J-Y, Deal CL (2013) Prevalence of oral glucocorticoid usage in the United States: a general population perspective. Arthritis Care Res 65(2):294–298

    Article  Google Scholar 

  26. Viktil KK, Enstad M, Kutschera J, Smedstad LM, Schjøtt J (2001) Polypharmacy among patients admitted to hospital with rheumatic diseases. Pharm World Sci 23(4):153–158

    Article  CAS  Google Scholar 

  27. Gladman DD, Urowitz MB, Rahman P, Ibañez D, Tam LS (2003) Accrual of organ damage over time in patients with systemic lupus erythematosus. J Rheumatol 30(9):1955–1959

    PubMed  Google Scholar 

  28. Sheane BJ, Gladman DD, Su J, Urowitz MB (2017) Disease outcomes in glucocorticosteroid-naive patients with systemic lupus erythematosus. Arthritis Care Res 69(2):252–256

    Article  CAS  Google Scholar 

  29. Proven A, Gabriel SE, Orces C, O'Fallon WM, Hunder GG (2003) Glucocorticoid therapy in giant cell arteritis: duration and adverse outcomes. Arthritis Rheum 49(5):703–708

    Article  CAS  Google Scholar 

  30. Hoffman GS, Kerr GS, Leavitt RY, Hallahan CW, Lebovics RS, Travis WD et al (1992) Wegener granulomatosis: an analysis of 158 patients. Ann Intern Med 116(6):488–498

    Article  CAS  Google Scholar 

  31. Shbeeb I, Challah D, Raheel S, Crowson CS, Matteson EL (2018) Comparable rates of glucocorticoid-associated adverse events in patients with polymyalgia rheumatica and comorbidities in the general population. Arthritis Care Res 70(4):643–647

    Article  CAS  Google Scholar 

  32. Agca R, Heslinga SC, Rollefstad S, Heslinga M, McInnes IB, Peters MJL et al (2017) EULAR recommendations for cardiovascular disease risk management in patients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis 76(1):17–28

    Article  CAS  Google Scholar 

  33. Condon MB, Ashby D, Pepper RJ, Cook HT, Levy JB, Griffith M, Cairns TD, Lightstone L (2013) Prospective observational single-centre cohort study to evaluate the effectiveness of treating lupus nephritis with rituximab and mycophenolate mofetil but no oral steroids. Ann Rheum Dis 72(8):1280–1286

    Article  CAS  Google Scholar 

  34. Gracia-Tello B, Ezeonyeji A, Isenberg D (2017) The use of rituximab in newly diagnosed patients with systemic lupus erythematosus: long-term steroid saving capacity and clinical effectiveness. Lupus Science & Medicine 4(1):e000182

    Article  Google Scholar 

  35. Walsh M, Merkel PA, Peh C-A, Szpirt WM, Puéchal X, Fujimoto S, Hawley CM, Khalidi N, Floßmann O, Wald R, Girard LP, Levin A, Gregorini G, Harper L, Clark WF, Pagnoux C, Specks U, Smyth L, Tesar V, Ito-Ihara T, de Zoysa JR, Szczeklik W, Flores-Suárez LF, Carette S, Guillevin L, Pusey CD, Casian AL, Brezina B, Mazzetti A, McAlear CA, Broadhurst E, Reidlinger D, Mehta S, Ives N, Jayne DRW (2020) Plasma exchange and glucocorticoids in severe ANCA-associated vasculitis. New Engl J Med 382(7):622–631

    Article  CAS  Google Scholar 

  36. Jayne DRW, Bruchfeld AN, Harper L, Schaier M, Venning MC, Hamilton P, Burst V, Grundmann F, Jadoul M, Szombati I, Tesař V, Segelmark M, Potarca A, Schall TJ, Bekker P (2017) Randomized trial of C5a receptor inhibitor avacopan in ANCA-associated vasculitis. J Amer Soc Nephrol 28(9):2756–2767

    Article  CAS  Google Scholar 

  37. Hunder GG, Sheps SG, Allen GL, Joyce JW (1975) Daily and alternate-day corticosteroid regimens in treatment of giant cell arteritis: comparison in a prospective study. Ann Intern Med 82(5):613–618

    Article  CAS  Google Scholar 

  38. Hoffman GS, Cid MC, Hellmann DB, Guillevin L, Stone JH, Schousboe J, Cohen P, Calabrese LH, Dickler H, Merkel PA, Fortin P, Flynn JA, Locker GA, Easley KA, Schned E, Hunder GG, Sneller MC, Tuggle C, Swanson H, Hernández-Rodríguez J, Lopez-Soto A, Bork D, Hoffman DB, Kalunian K, Klashman D, Wilke WS, Scheetz RJ, Mandell BF, Fessler BJ, Kosmorsky G, Prayson R, Luqmani RA, Nuki G, McRorie E, Sherrer Y, Baca S, Walsh B, Ferland D, Soubrier M, Choi HK, Gross W, Segal AM, Ludivico C, Puechal X, International Network for the Study of Systematic Vasculitides (INSSYS) (2002) A multicenter, randomized, double-blind, placebo-controlled trial of adjuvant methotrexate treatment for giant cell arteritis. Arthritis Rheum 46(5):1309–1318

    Article  CAS  Google Scholar 

  39. Villiger PM, Adler S, Kuchen S, Wermelinger F, Dan D, Fiege V, Bütikofer L, Seitz M, Reichenbach S (2016) Tocilizumab for induction and maintenance of remission in giant cell arteritis: a phase 2, randomised, double-blind, placebo-controlled trial. Lancet 387(10031):1921–1927

    Article  CAS  Google Scholar 

  40. Panush RS (1996) Plus ca change, plus cʼest la meme chose. J Clin Rheum 2(3):172

    Article  CAS  Google Scholar 

  41. Mofrad A, Rajbhandary R, Panush RS (2014) The art and science of tapering glucocorticoids in patients with rheumatic diseases. J Rheumatol 41(6):1252

    Article  Google Scholar 

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  1. Division of Rheumatology, Department of Medicine, Keck School of Medicine, University of Southern California and Los Angeles County + University of Southern California (LAC+USC) Medical Center, Los Angeles, CA, USA

    Sky Wang & Richard S. Panush

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  1. Sky Wang
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Correspondence to Richard S. Panush.

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This work was approved by the University of Southern California Institutional Review Board (IRB # HS-18-01002, How Do Rheumatologists Use Corticosteroids for Managing Sick Patients in the Hospital, approved 3/28/2019).

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Wang, S., Panush, R.S. Certain perspectives about the use of corticosteroids for managing hospitalized patients with rheumatic diseases. Clin Rheumatol 39, 3131–3136 (2020). https://doi.org/10.1007/s10067-020-05349-0

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  • DOI: https://doi.org/10.1007/s10067-020-05349-0

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