Association of Cardiovascular Outcomes with Low-Dose Glucocorticoid Use in Patients with Rheumatoid Arthritis.

OBJECTIVE: Many guidelines recommend limiting glucocorticoids in patients with rheumatoid arthritis (RA), but 40% of patients remain on glucocorticoids long-term. We evaluated the cardiovascular risk of long-term glucocorticoid use by studying patients on stable disease modifying anti-rheumatic drugs (DMARDs).

METHODS: Using two claims databases, we identified patients with RA on stable DMARD therapy for >180 days. Proportional hazards models with inverse probability weights and clustering to account multiple observations were used to estimate the effect of glucocorticoid dose on composite cardiovascular outcomes (stroke or myocardial infarction).

RESULTS: There were 135,583 patients in Medicare and 39,272 in Optum's de-identified Clinformatics® Data Mart (CDM) database. Medicare and CDM patients had an incidence of 1.3 and 0.8 composite cardiovascular outcomes per 100 person-years, respectively. In the older, comorbid Medicare cohort, glucocorticoids were associated with a dose-dependent increase in composite cardiovascular outcomes in adjusted models with predicted 1-year incidence of 1.4% (95% CI 1.2-1.6) for ≤5mg, 1.6% (1.4-1.9) for >5-10mg, and 1.8% (1.2-2.5) for >10mg versus 1.1% (95% CI 1.1-1.2) among patients using no glucocorticoids. There was no significant association among the CDM cohort. However, in the subgroup of younger patients with RA and higher cardiovascular risk, glucocorticoids were associated with a dose-dependent increase in composite cardiovascular outcomes.

CONCLUSION: Among older, more comorbid and younger, higher cardiovascular risk patients with RA on stable DMARD therapy, glucocorticoids were associated with a dose-dependent increased risk of myocardial infarction and stroke, even at doses ≤5mg/d. By contrast, no association was noted among younger, healthier patients with RA.