PHILADELPHIA – The use of prednisone therapy, especially in high doses, increases the odds that a person with rheumatoid arthritis will develop an infection, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in Philadelphia, Pa.
Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.
Researchers recently compared the use of different combinations of immunosuppressive RA therapies, specifically TNF inhibitors and conventional disease-modifying antirheumatic drugs (commonly called DMARDs) such as methotrexate, leflunomide hydroxychloroquine or sulfasalazine, TNF–inhibitors (i.e., infliximab, etanercept, or adalimumab) and corticosteroids, including prednisone, to the risk of infection in people with RA.
Researchers used both the VA National Patient Care Database and the Pharmacy Benefits Management Database to identify cases of RA from October 1, 2000 through September 30, 2007. By definition, patients with RA had had two outpatient visits at least 30 days apart or one inpatient visit, and had had at least one prescription for a DMARD. They determined that approximately 35 percent of patients are on prednisone, which is mostly used in those whose RA is difficult to control with DMARDS or TNF inhibitors alone.
The researchers examined 3,457 cases of RA patients with a serious infection (i.e., requiring hospitalization) as well as patients with RA who had not experienced a serious infection. The study showed that the use of any prednisone, especially in high doses, was associated with increased odds of infection in RA when added to an anti-TNF or DMARD, from either of two groups: methotrexate/leflunomide and sulfasalazine/hydroxychloroquine.
The risk of serious infection with a TNF- inhibitor alone was similar to that of a DMARD when combined with a low dose of prednisone. The combination of a TNF–inhibitor, two or more DMARDs, and any dosage of prednisone was associated with the highest odds of serious infection. The presence of other conditions and/or anemia also increased the risk of infection.
“Although drugs such as corticosteroids or TNF inhibitors may increase the risk of infection, they are often necessary to control RA,” explains Eduardo Bonilla Trejos, MD; staff physician, Pittsburgh VA Healthcare, Pittsburgh, Pa., and lead investigator in the study. “The important message is that if a patient with RA requires a combination of a TNF–inhibitor, DMARDs and corticosteroids to manage their disease, both patients and their rheumatologists should be particularly vigilant to the possibility of infection, especially in the presence of comorbid conditions and/or anemia.”
Patients should talk to their rheumatologists to determine their best course of treatment.
http://www.rheumatology.org/press/2009/2009_am_01.asp