The use of steroids, like prednisolone, for certain rheumatic conditions may increase the risk of both viral and bacterial infections. Yet doctors have limited options.
In a study published today in the Canadian Medical Association Journal (CMAJ), researchers found a strong association between glucocorticoids and different forms of infection in individuals with two common rheumatic illnesses.
The study used the electronic health records of nearly 40,000 people with either polymyalgia rheumatica, giant cell arteritis, or both in England between 1997 and 2017. Researchers identified a “dose response risk” between steroids and infection, meaning the higher the prescribed dose, the more likely an infection occurred.
“Steroids are effective in reducing inflammation and symptoms, but they also reduce the ability of the immune system to fight infections. Doctors and scientists know steroids increase the risk of infection, but no one has calculated this risk in a way that is useful to patients, clinicians, and decision makers,” said Dr. Mar Pujades Rodriguez, a University Academic Fellow at the University of Leeds and one of the authors of the study.
Pujades Rodriguez and her team found that the risk of infection increased even with low doses of steroids — less than 5 milligrams of prednisolone — a commonly prescribed glucocorticoid.
For every increase of 5 mg in the daily dose of prednisolone, risk of infection increased by 13 percent. Risk of infection also increased the longer the steroids were prescribed. For individuals taking higher doses (25 mg per day or more) risk of infection nearly tripled after one-year follow-up.
The association was most clear for bacterial and viral infections.
“Clearly the bacterial and the viral go up aggressively as you get to the higher dosage ranges,” said Dr. Jason Faller, rheumatologist at Lenox Hill Hospital, NYC.
“The higher the dose, the longer the duration, the more the risk to the individual,” added Faller, who wasn’t associated with the research.
Of the nearly 40,000-person cohort, a little over half experienced an infection during a median five-year follow-up period. The most common types of infections were chest infections, conjunctivitis (pink eye), and shingles.
Infections frequently resulted in serious outcomes: More than one-quarter who experienced them were hospitalized, and 7 percent died within a week of the diagnosis of their infection.
The study highlights some of the difficult risk/benefit decisions doctors and patients have to make for conditions with limited treatment options.
Both large cell arteritis and polymyalgia rheumatica occur primarily in older individuals. It’s not uncommon for both conditions to manifest concurrently. The majority of cases occur in people over 50 and are more common in women.
Seniors are also more prone to infections, and the use of glucocorticoids or other corticosteroids increases that risk. However, there’s little they can do with the few treatment options available to them.
“These conditions are progressive, debilitating, and need to be treated,” said Faller.
“In polymyalgia rheumatica, which is the more common of the two conditions they studied here, there is no other indicated treatment other than steroids… We are stuck, we have no choice. There is no other known, approved effective therapy,” he said.
Pujades Rodriguez hopes that her work will help to better inform doctors and patients about the risks, but also to encourage diligence in responsible treatment, preventative care, and helping in the assessment of future drugs that come to market.
“Patients with polymyalgia rheumatica and giant cell arteritis and clinicians should be educated about the risk of infection, the need to identify the symptoms of infection, prompt treatment, timely vaccination and documentation of history of chronic infections,” she said.
Responsible treatment means only prescribing the lowest necessary dose of steroids, which should be taken for as short a time period as possible. Vaccinations, for illnesses such as herpes zoster (shingles), are also an important part of care for older individuals who need to be prescribed corticosteroids.
While the research focused solely on large cell arteritis and polymyalgia rheumatica, it is likely that the trends in dose-response infection risk from glucocorticoids would prevail in patients with other forms of rheumatic disease as well.
“I would think that the trend is similar in any condition in which you are using corticoids,” said Faller.
Polymyalgia rheumatica is an inflammatory disorder that causes stiffness and muscle pain. The most commonly affected areas include the shoulders, neck, arms, and hips. The average onset is near age 70. About 15 percent of people with polymyalgia rheumatica also develop giant cell arteritis, which is also known as temporal arteritis.
Giant cell arteritis is the most
Symptoms include jaw pain, double vision, headache located primarily in the temples, and fatigue.
Serious complications can occur from giant cell arteritis, including stroke, aneurysms, and blindness. It is recommended that individuals seek the opinion of a doctor if any of the above symptoms occur.
For patients currently taking corticosteroids, it is not recommended to stop taking them or to change the dose without speaking to a doctor.
“We would like to stress that it is dangerous to stop taking steroids suddenly,” said Pujades Rodriguez.
“This is because the steroids that are taken as treatments can reduce the amount of natural steroids produced by the body, and so it is important that the body is given time to adjust and start producing again the natural steroids.”