New research was presented at EULAR 2022, the European Alliance for Associations for Rheumatology Annual Meeting, from June 1-4 in Copenhagen, Denmark, and virtually. The features below highlight some of the studies emerging from the sessions.
Long-Term Corticosteroids Safe & Effective in Older Patients With RA
Clinicians routinely prescribe steroids indefinitely believing that they enhance the benefits of disease-modifying drugs, according to Maarten Boers, MD, PhD, and colleagues, despite ACR and EULAR guidelines recommending steroids solely for temporary treatment. With a lack of adequately powered, randomized, placebo-controlled trials assessing long-term steroid use in RA, Dr. Boers and team conducted a randomized trial to study the effects of prednisone in 451 older patients with DAS28 scores of at least 2.60 who did not have conditions that could be impaired by prednisolone. Patients were randomized 1:1 to steroid or to placebo and continued receiving their usual RA treatments. While mean DAS28 scores fell markedly within a few months in both groups, the degree of improvement was greater in the prednisone group and remained throughout the trial. The mean DAS28 score was lower by 0.37 points at the final follow-up in those receiving prednisolone versus placebo. During the trial, the prednisolone group also experienced fewer erosions and less joint space narrowing. “These results are immediately applicable in clinical practice,” Dr. Boers said.
Methotrexate Slows Arthritis Development
In clinically suspected arthralgia, the temporary use of methotrexate delays, but does not prevent, the development of clinical arthritis. According to the 2-year Treat Earlier study, use of the agent lead to sustained reduction of disease burden and inflammation in all at-risk groups. Doortje Krijbolder, MD, and colleagues conducted a randomized, double-blinds study to determine if administering methotrexate in the pre-arthritis phase of arthralgia prevents the development of clinical arthritis or reduces disease burden. All participants presented with arthralgia of the small joints that was clinically suspect for progression to RA over time and were randomized (1:1) to a single intramuscular glucocorticoid injection and a 1-year course of oral methotrexate or to placebo and then followed for a year without medication to observe any disease progression. Treatment and placebo groups matched with an average age of 46-47, 62%-68% were female, they had presented with joint pain for 27-28 weeks, 20%-26% were anti-citrullinated protein autoantibody positive, and C-reactive protein was increased in 27%-30%. No differences were observed between treatment and placebo groups in overall arthritis development. However, in the high-risk group sub-analysis, 67% in the placebo group developed persistent clinical arthritis. In the treatment group, 67% developed persistent clinical arthritis at 24 months, 40% at 18 months, 27% at 12 months, and 7% at 6 months. For the placebo group, 67% developed persistent clinical arthritis at 12, 18, and 24 months, and 56% developed it at 6 months.
Foot & Ankle Pain Linked With 83% Increased Risk for Health-Related Job Loss
Foot and ankle pain (FAP) is a risk factor for health-related job loss (HRJL) among older working adults, particularly if their job involves stair climbing, according to Johanna Sigaux, MD, and colleagues. The researchers conducted a longitudinal, population-based cohort investigation of 4,050 participants (Health And Employment After Fifty). Participants were asked to show on a full-body mannequin where they felt pain. At 2-year follow-up, participants were asked whether they had left employment in order to determine correlations between FAP, HRJL, and other risk factors. The study group performed a sensitivity analysis to assess which occupational activities were notably linked with HRJL due to FAP. Among participants with HRJL, 108 had non-FAP pain, 54 had FAP, and 73 had no pain. People with FAP had an 83% increased risk for HRJL compared with people with no pain, after adjusting for age and sex, while those with non-FAP pain had 34% increased risk. “Sensitivity analyses confirmed that doing jobs that involved climbing more than 30 flights of stairs was associated with increased risk for HRJL amongst people with FAP,” Dr. Sigaux and team wrote. “Potentially, modification of duties to reduce stair climbing could mitigate job loss amongst people with FAP.”
High Maternal & Fetal Morbidity Rates in Pregnant Women With SLE
Pregnant women with systemic lupus erythematosus (SLE) have a considerably greater risk for complications during childbirth than pregnant women without SLE, according to Bella Mehta, MBBS, MS, MD, who noted that these complications include requiring a transfusion, developing acute renal failure, or developing a cerebrovascular disorder. Based on the review of data from a national sample, Dr. Mehta added that pregnant women with SLE have a two-fold higher risk for premature delivery, and a three-fold greater risk for having a fetus with intrauterine growth restriction. The study team assessed retrospective data on 40 million delivery-related admissions from 2008-2017, among which 51,161 women had SLE. A total of 21 severe maternal morbidity outcomes were identified, including blood transfusion requirements, eclampsia and disseminated intravascular coagulation, cardiovascular and peripheral vascular disorders, and general medical issues, such as adult respiratory distress syndrome, hysterectomy, sepsis, severe anesthesia complications, shock, temporary tracheostomy, and ventilation. Women with SLE were slightly older at delivery (mean age, 30.05 vs 29.19) and had more comorbidities (97.84% had 1-4, compared with 19.4% of women without SLE). “Severe maternal morbidity and fetal morbidity still remain high, but this work can help inform physicians and counsel patients for pregnancy planning and management,” Dr. Mehta said.
TNF Placental Transfer Has Little Effect on Offspring Infections
For pregnant women with rheumatic diseases being treated with tumor necrosis factor alpha (TNFα) inhibitors, there appears to be an insignificant risk for serious infections in children exposed in utero to TNF inhibitors with high, compared with low, placental transfer. Leah Flatman, PhD-candidate, and colleagues conducted a study of nearly 3,000 infants exposed to TNF inhibitors during gestation. The study team conducted a population cohort study, evaluating data on offspring of mothers with RA, psoriatic arthritis and/or inflammatory bowel diseases (IBD), and ankylosing spondylitis. In the 6 months before delivery, exposure consisted of at least one filled prescription and/or infusion procedure claim for TNF inhibitors. Among 26,088 offspring, 11% were exposed in utero to a TNF inhibitor. Of 2,105 children of mothers treated with a high placental-transfer drug, 1.8% developed serious infections, compared with 1.3% of mothers who received low placental-transfer drugs. A multivariable analysis found that the risk for serious infection in the high, compared with the low, placental-transfer group was 1.20—indicating non-significance—with any RA diagnosis with or without a diagnosis of IBD, disease-modifying antirheumatic drug use, gestational or pregestational diabetes, maternal asthma, or preterm delivery. “Our data are reassuring as we saw no strong signal, which suggests that there is no need to switch the mother’s drugs,” Flatman said, adding that although further research is needed, the study is “a step in the right direction to reduce maternal stress and reassure physicians.”