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Glucocorticoid discontinuation in patients with early rheumatoid and undifferentiated arthritis: a post-hoc analysis of the BeSt and IMPROVED studies
  1. Johanna Maria Maassen1,
  2. Raquel Dos Santos Sobrín2,
  3. Sytske Anne Bergstra1,
  4. Robbert Goekoop3,
  5. Tom W J Huizinga1,
  6. Cornelia F Allaart1
  1. 1Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
  2. 2Rheumatology, Clinical University Hospital of Santiago de Compostela, Santiago de Compostela, Spain
  3. 3Rheumatology, HagaZiekenhuis, Den Haag, The Netherlands
  1. Correspondence to Dr Johanna Maria Maassen, Rheumatology, Leiden University Medical Center, Leiden 2333 ZA, The Netherlands; j.m.maassen{at}lumc.nl

Abstract

Objectives To evaluate the success rate of glucocorticoid discontinuation and to study which factors are associated with successful discontinuation.

Methods Data from two treat-to-target studies, BeSt (target Disease Activity Score (DAS) ≤2.4) and IMPROVED (target DAS <1.6), were evaluated for all patients initially treated with a tapered high dose of prednisone with conventional synthetic disease-modifying antirheumatic drugs. Prednisone was discontinued when DAS ≤2.4 was maintained for 28 weeks in BeSt and as soon as DAS was <1.6 in IMPROVED. Discontinuation was considered successful if the target was maintained at the next visit. Logistic regression analyses were performed to identify predictors of successful discontinuation. A mixed effects logistic regression model was used to assess whether primary versus secondary discontinuation was as successful.

Results In the BeSt study, 40% (47 of 93) of patients flared after primary prednisone discontinuation, and of the other 60% (56 of 93), 38% had to restart later. Of those who restarted (secondary discontinuation), 47% (17 of 35) again flared. In IMPROVED, after primary discontinuation 39% (158 of 400) flared, and of the other 61% (242 of 400), 40% had to restart later. After secondary discontinuation 49% (68 of 139) flared. Only in IMPROVED a secondary attempt was less successful (BeSt OR 0.71, p=0.45; IMPROVED OR 0.60, p=0.01). A lower DAS both at baseline and stop visit and male gender (in IMPROVED) were associated with successful primary discontinuation.

Conclusion Primary glucocorticoid discontinuation resulted in direct loss of disease control in approximately 40% and secondary in 50% of patients. ‘Standard’ baseline characteristics seem insufficient to personalise the duration of temporary glucocorticoid bridging, but the DAS at the time of discontinuation might provide guidance.

  • rheumatoid arthritis
  • glucocorticoids
  • treatment

Data availability statement

Data are available upon reasonable request. The datasets used and/or analysed during the present study are available from the corresponding author on reasonable request.

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Data availability statement

Data are available upon reasonable request. The datasets used and/or analysed during the present study are available from the corresponding author on reasonable request.

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Footnotes

  • Handling editor Josef S Smolen

  • JMM and RDSS contributed equally.

  • Contributors JMM, RDSS, SAB and CFA contributed to the design, analysis and interpretation of the data. RG, TWJH and CFA contributed to data acquisition. JMM and RDSS drafted the manuscript. All authors critically revised the manuscript and read and approved the final version of the manuscript to be published.

  • Funding The BeSt study was designed by the investigators and supported by a government grant from the Dutch Insurance Companies, with additional funding from Schering-Plough and Janssen. Data collection, trial management, data analysis and preparation of the manuscript were performed by the authors. The IMPROVED study was designed by the investigators and financially supported by AbbVie in the first year. Trial management, data collection, data analysis and preparation of the manuscript were performed by the authors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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