Study: Patients Receiving Low Dose Steroid at Increased Risk of Cardiovascular Disease

A study published in PLOS Medicine observed an increased risk of cardiovascular diseases (CVDs) associated with glucocorticoid dose intake even at lower doses in 6 immune-mediated diseases. These findings highlight the importance of prompt, regular monitoring of cardiovascular risk and use of primary prevention treatment at all glucocorticoid doses, according to the authors.

The objective of the study was to quantify glucocorticoid dose-dependent cardiovascular risk in people with 6 immune-mediated inflammatory diseases. Glucocorticoids are widely used to reduce disease activity and inflammation in patients with a range of immune-mediated inflammatory diseases. However, it is unclear whether or not low to moderate glucocorticoid dose increases cardiovascular risk, according to the study authors.

The researchers conducted a population-based cohort analysis of medical records from 389 primary care practices contributing data to the United Kingdom Clinical Practice Research Datalink for hospital admissions and deaths from 1998 to 2017. Further, the team estimated time-variant daily and cumulative glucocorticoid prednisolone-equivalent dose-related risks and hazard ratios of first all-cause and type-specific CVDs.

In the study, 87,794 patients with giant cell arteritis and/or polymyalgia rheumatica, inflammatory bowel disease, rheumatoid arthritis, systemic lupus erythematosus, and/or vasculitis, and no prior CVD. The mean age was 56 years and 34.1% were men. Additionally, the median follow-up time was 5 years, and the proportions of person-years spent at each level of glucocorticoid daily exposure were 80% for non-use, 6.0% for less than 5 mg, 11.2% for 5 to 14.9 mg, 1.6% for 15 to 24.9 mg, and 1.2% for more than or equal to 25 mg.

The results showed that incident CVD occurred in 15.3% of people, including 6013 atrial fibrillation events, 7727 heart failure events, and 2809 acute myocardial infarction events. The 1-year cumulative risks of all-cause CVD increased from 1.4% in periods of non-use to 8.9% for a daily prednisolone-equivalent dose of greater than or equal to 25 mg. The 5-year cumulative risks increased from 7.1% to 28%, respectively.

Compared with periods of non-glucocorticoid use, those with less than 5 mg daily prednisolone-equivalent dose had increased all-cause CVD risk. Further, increased dose-dependent risk ratios were found regardless of disease activity level and for all type-specific CVDs.

Limitations of the study include a lack of hospital medication records and drug adherence data that might have led to an underestimation of the dose prescribed when specialists provided care and overestimation of the dose taken during periods of low disease activity, according to the authors. Therefore, the resulting dose misclassification in some patients is likely to have reduced the size of dose-response estimates, the researchers concluded.

REFERENCE

Pujades-Rodriguez M, Morgan AW, Cubbon RM, et al. Dose-dependent oral glucocorticoid cardiovascular risks in people with immune-mediated inflammatory diseases: A population-based cohort study. PLOS Medicine. December 3, 2020. https://doi.org/10.1371/journal.pmed.1003432.