Xie Wenhui, Huang Hong, Zhang Zhuoli
Department of Rheumatology and Clinical Immunology, Peking University First Hospital, No. 8, Xishiku Street, West District, Beijing, 100034, China.
Rheumatol Ther. 2023 Apr;10(2):405-419. doi: 10.1007/s40744-022-00527-9. Epub 2023 Jan 6.
Glucocorticoids (GC) are currently recommended as a bridging therapy in combination with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARD) for the treatment of rheumatoid arthritis (RA) and should be tapered as rapidly as clinically feasible. We aimed to explore potential predictors for GC discontinuation in patients commencing GC with concomitant csDMARD.
We used data from a longitudinal real-world cohort. RA patients who newly started GC concomitantly with csDMARD were included. All patients were divided into four groups, according to degree of change in disease activity at 3 months from baseline (group 1: worsening or no decrease; group 2: 0-24.9% decrease; group 3: 25.0-49.9% decrease; group 4: ≥ 50.0% decrease). Cox regression was used to estimate hazard risk (HR) with 95% confidence interval (CI).
In total, 124 out of 207 RA patients discontinued GC at the rheumatologist's discretion and 79.1% (91/115) of them successfully stopping GC without flare within 6 months after GC withdrawal. Increasing age (HR 0.99, 95% CI 0.98-1.00, p = 0.043) and concomitant nonsteroidal anti-inflammatory drugs use at GC initiation (HR 0.47, 95% CI 0.25-0.88, p = 0.018) were independently associated with GC withdrawal failure. Moreover, the degrees of disease activity improvement at 3 months significantly predicted the possibility of subsequent GC discontinuation (fully adjusted HR 1.35-1.47, p < 0.01), with 2.38-3.59 times higher in group 4 than group 1. Switching the outcome to successfully stopping GC without short-term flare yielded similar findings.
The degrees of disease activity improvement at 3 months independently predicted the subsequent GC withdrawal. These findings suggest the importance of dynamic treatment strategies with a closer look at disease activity during GC tapering and discontinuation.
目前推荐使用糖皮质激素（GC）联合传统合成改善病情抗风湿药（csDMARD）作为类风湿关节炎（RA）的过渡治疗，且应在临床可行的情况下尽快减停。我们旨在探索开始使用GC联合csDMARD治疗的患者中GC停药的潜在预测因素。
我们使用了来自一个纵向真实世界队列的数据。纳入了新开始同时使用GC和csDMARD的RA患者。所有患者根据与基线相比3个月时疾病活动度的变化程度分为四组（第1组：病情恶化或无改善；第2组：降低0 - 24.9%；第3组：降低25.0 - 49.9%；第4组：降低≥50.0%）。采用Cox回归估计风险比（HR）及95%置信区间（CI）。
207例RA患者中，共有124例由风湿病学家决定停用GC，其中79.1%（91/115）的患者在GC撤药后6个月内成功停药且无病情复发。年龄增加（HR = 0.99，95%CI 0.98 - 1.00；p = 0.043）以及开始使用GC时同时使用非甾体抗炎药（HR = 0.47；95%CI0.25 - 0.88；p =0.018）与GC撤药失败独立相关。此外，3个月时疾病活动度的改善程度显著预测了随后停用GC的可能性（完全调整后的HR为1.35 - 1.47；p < 0.01），第4组比第1组高2.38 - 3.59倍。将结局改为成功停药且无短期病情复发也得到了类似结果。
3个月时疾病活动度的改善程度可独立预测随后的GC撤药。这些发现提示了动态治疗策略的重要性，即在GC减量和停药期间更密切地关注疾病活动度。
