Even Small Doses of Glucocorticoids Can Significantly Increase Infection Risk

Philadelphia, PA—Even low doses of glucocorticoids present significantly increased risk of infection, according to a new study that suggests that prescribers need to take that into consideration in treating chronic disease such as rheumatoid arthritis (RA).

The report in Annals of Internal Medicine points out that low-dose glucocorticoids are frequently used for the management of RA and other conditions, but the safety of long-term use remained  unclear.

University of Pennsylvania–led researchers sought to quantify the risk for infection requiring hospitalization with long-term use of low-dose glucocorticoids in patients with RA receiving stable disease-modifying antirheumatic drug (DMARD) therapy. That is important, they explain, because, although the treatment goal is usually short-term use, up to 60% of RA patients remain on long-term glucocorticoids, especially at low doses. 

The retrospective cohort study used Medicare claims data and Optum’s deidentified Clinformatics Data Mart database from 2006 to 2015. Included in the study were adults with RA receiving a stable DMARD regimen for more than 6 months.

The focus was on associations between glucocorticoid dose—none, ≤5 mg/d, >5 to 10 mg/d, and >10 mg/d—and infection requiring hospitalization.

Researchers wrote that 247,297 observations were identified among 172,041 Medicare patients and 58,279 observations among 44,118 patients in Optum. After 6 months of stable DMARD use, 47.1% of Medicare patients and 39.5% of Optum patients were receiving glucocorticoids, according to the study team.

Results indicate that the 1-year cumulative incidence of hospitalized infection in Medicare patients not receiving glucocorticoids was 8.6% versus 11.0% (95% CI, 10.6%-11.5%) for glucocorticoid dose of 5 mg or less per day, 14.4% (CI, 13.8%-15.1%) for greater than 5 to 10 mg/d, and 17.7% (CI, 16.5%-19.1%) for greater than 10 mg/d (all P <.001 vs. no glucocorticoids).

In addition, the authors note, the 1-year cumulative incidence of hospitalized infection in Optum patients not receiving glucocorticoids was 4.0% versus 5.2% (CI, 4.7%-5.8%) for a glucocorticoid dose of 5 mg or less per day, 8.1% (CI, 7.0%-9.3%) for greater than 5 to 10 mg/d, and 10.6% (CI, 8.5%-13.2%) for greater than 10 mg/d (all P <.001 vs. no glucocorticoids).

“In patients with RA receiving stable DMARD therapy, glucocorticoids were associated with a dose-dependent increase in the risk for serious infection, with small but significant risks even at doses of 5 mg or less per day,” the researchers conclude. “Clinicians should balance the benefits of low-dose glucocorticoids with this potential risk.”

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