Even low-dose oral glucocorticoid use associated with increased CV risk
medwireNews: UK research has identified a “strong dose-dependent” association between oral glucocorticoid use and cardiovascular disease (CVD) risk among people with immune-mediated diseases, with an increased risk seen even at prednisolone-equivalent doses of less than 5 mg/day.
“These results highlight the importance of prompt and regular monitoring of cardiovascular risk and use of primary prevention treatment at all glucocorticoid doses,” write the researchers in PLOS Medicine.
Mar Pujades-Rodriguez and colleagues from the University of Leeds used the UK Clinical Practice Research Datalink primary care database coupled with data on hospital admissions and deaths in 1998–2017 to analyze CV risk in 87,794 patients with one or more immune-mediated inflammatory diseases and no prior CVD, of whom 16.4% had been prescribed oral glucocorticoids in the previous year.
A total of 29.1% of patients had a diagnosis of polymyalgia and/or giant cell arteritis (GCA), 28.8% had rheumatoid arthritis, 5.9% vasculitis, and 4.5% systemic lupus erythematosus (SLE), while 31.6% had inflammatory bowel disease. Patients were aged an average of 56 years and 34.1% were men.
In all, 13,426 incident CV events occurred in 15.3% of patients during a median follow-up of 5.0 years, giving an incidence rate of 24.8 per 1000 person–years.
The estimated cumulative incidence of all-cause CVD at 1 year was 1.4% for periods of no glucocorticoid use, rising to 3.8% for prednisolone-equivalent doses of less than 5 mg/day, 4.8% for doses of 5.0–14.9 mg/day, 7.2% for doses of 15.0–24.9 mg/day, and 8.9% for higher doses. These findings translated into a significant 9% increased CVD risk with each 5 mg increase in daily glucocorticoid dose after adjustment for a range of factors including age, sex, BMI, and comorbidities.
Pujades-Rodriguez and team said that when individual immune-mediated diseases and CV events were analyzed separately, there were “strong dose-dependent increases in hazards of […] atherosclerotic diseases, heart failure, atrial fibrillation, and abdominal aortic aneurysm, regardless of the underlying immune-mediated disease, its activity, and duration.”
Compared with periods of no glucocorticoid use, the hazard ratio for CVD associated with a daily dose of less than 5 mg ranged from 1.50 among patients with polymyalgia rheumatica and/or GCA to 2.81 for SLE, while HRs for individual CV events associated with the lowest dose ranged from 1.32 for cerebrovascular disease to 1.93 for abdominal aortic aneurysm.
Noting that patients in the study had a “high prevalence of modifiable risk factors,” including obesity (24.5%) and current smoking (24.2%), the researchers say that their findings highlight “the need to implement and evaluate intensive lifestyle modification interventions” among people receiving glucocorticoid treatment.
They add: “Our findings also emphasise the importance of rapid glucocorticoid dose tapering and discontinuation as soon as disease control is achieved, as well as the importance of evaluating the safety profile of alternative therapeutic options for patients with autoimmune-mediated inflammatory diseases.”
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