Incidence and Risk of Glucocorticoid-Associated Adverse Effects in Patients With Rheumatoid Arthritis

European Society of Endocrinology and Endocrine Society Joint Clinical Guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency

Glucocorticoids are widely prescribed as anti-inflammatory and immunosuppressive agents. This results in at least 1% of the population using chronic glucocorticoid therapy, being at risk for glucocorticoid-induced adrenal insufficiency. This risk is dependent on the dose, duration and potency of the glucocorticoid, route of administration, and individual susceptibility. Once glucocorticoid-induced adrenal insufficiency develops or is suspected, it necessitates careful education and management of affected patients. Tapering glucocorticoids can be challenging when symptoms of glucocorticoid withdrawal develop, which overlap with those of adrenal insufficiency. In general, tapering of glucocorticoids can be more rapidly within a supraphysiological range, followed by a slower taper when on physiological glucocorticoid dosing. The degree and persistence of HPA axis suppression after cessation of glucocorticoid therapy are dependent on overall exposure and recovery of adrenal function varies greatly amongst individuals. This first European Society of Endocrinology/Endocrine Society joint clinical practice guideline provides guidance on this clinically relevant condition to aid clinicians involved in the care of patients on chronic glucocorticoid therapy.

Comprehensive insights into rheumatoid arthritis: Pathophysiology, current therapies and herbal alternatives for effective disease management

Rheumatoid arthritis is a chronic autoimmune inflammatory disease characterized by immune response overexpression, causing pain and swelling in the synovial joints. This condition is caused by auto-reactive antibodies that attack self-antigens due to their incapacity to distinguish between self and foreign molecules. Dysregulated activity within numerous signalling and immunological pathways supports the disease's development and progression, elevating its complexity. While current treatments provide some alleviation, their effectiveness is accompanied by a variety of adverse effects that are inherent in conventional medications. As a result, there is a deep-rooted necessity to investigate alternate therapeutic strategies capable of neutralizing these disadvantages. Medicinal herbs display a variety of potent bioactive phytochemicals that are effective in the complementary management of disease, thus generating an enormous potency for the researchers to delve deep into the development of novel phytomedicine against autoimmune diseases, although additional evidence and understanding are required in terms of their efficacy and pharmacodynamic mechanisms. This literature-based review highlights the dysregulation of immune tolerance in rheumatoid arthritis, analyses the pathophysiology, elucidates relevant signalling pathways involved, evaluates present and future therapy options and underscores the therapeutic attributes of a diverse array of medicinal herbs in addressing this severe disease.

All-trans retinoic acid alleviates collagen-induced arthritis and promotes intestinal homeostasis

All-trans retinoic acid (ATRA) has emerged as a promising adjunctive treatment for rheumatoid arthritis. However, the mechanism by which ATRA mitigates arthritis remains unclear. In this study, we aimed to explore ATRA alleviation of arthritis and the role of ATRA in regulating intestinal homeostasis. Thus, we established a collagen-induced arthritis (CIA) model in Wistar rats. After 6 weeks of ATRA treatment, the arthritis index of CIA rats decreased, synovial inflammation was alleviated, and the disruption of Th17/Treg differentiation in peripheral blood was reversed. Additionally, the Th17/Treg ratio in the mesenteric lymph nodes decreased and the expression of Foxp3 mRNA increased and that of IL-17 mRNA decreased in the colon and ileum. Microscopically, we observed reduced intestinal inflammation. Transmission electron microscopy revealed that ATRA could repair tight junctions, which was accompanied by an increase in the expression of Claudin-1, Occludin and ZO-1. Moreover, ATRA regulated the composition of the gut microbiota, as was characterized based on the reduced abundance of Desulfobacterota and the increased abundance of Lactobacillus. In conclusion, ATRA demonstrates the potential to alleviate arthritis in CIA rats, which might be correlated with modulating the gut microbiota and regulating the intestinal immune response. Our findings provide novel insights into ATRA-mediated alleviation of arthritis.

A first-in-human study of the novel immunology antibody-drug conjugate, ABBV-3373, in healthy participants

AIMS

ABBV-3373, an immunology antibody-drug conjugate composed of adalimumab conjugated to a proprietary glucocorticoid receptor modulator (the small-molecule payload), has the potential to treat immune-mediated inflammatory diseases. This first-in-human study investigated the pharmacokinetics (PK), immunogenicity, pharmacodynamics (PD) using a safety PD marker, and safety/tolerability of ABBV-3373 in healthy adults.

METHODS

Fifty-five participants were randomly assigned to single-dose subcutaneous (SC; 30, 100 or 300 mg) or intravenous (IV; 30, 300 or 900 mg) ABBV-3373 or placebo. Eight additional participants received a single dose of 10 mg oral prednisone for evaluation of systemic glucocorticoid effects. Blood samples were collected for up to 85 days postdose for PK, anti-drug antibody and serum cortisol (safety PD marker) assessments.

RESULTS

ABBV-3373 and total antibody displayed antibody-like SC/IV PK profiles and the unconjugated/free payload in circulation exhibited formation rate-limited kinetics with exposure several fold lower than ABBV-3373 or total antibody. Treatment-emergent anti-drug antibody incidence was 69%, with loss of exposure in 6% (SC) and 5% (IV) of participants, but without any impact on safety. ABBV-3373 up to 300 mg SC/IV had no apparent impact on serum cortisol, and only caused a transient decrease at 900 mg IV. Treatment-emergent adverse events were primarily mild in severity, and no pattern emerged with respect to dose or route of administration.

CONCLUSIONS

ABBV-3373 had favourable PK profiles, manageable immunogenicity, and was generally well-tolerated. Except for a transient effect at 900 mg IV, there was no apparent impact on serum cortisol. Study results supported further clinical development of ABBV-3373.

Pattern and Predictors of Infection Among Patients With Rheumatological Disease on Immunosuppressive Medications: A Retrospective Study in a Tertiary Care Hospital in Bangladesh

Background Immunomodulatory therapy for chronic rheumatic disease carries a risk for infectious complications. In Bangladesh, there is limited information regarding patterns and factors associated with infections among patients receiving immunosuppressive medications. Objective The present study aimed to find out patterns and predictors associated with infection among patients who were on different immunosuppressive medications due to chronic rheumatological disease. Methodology This was a retrospective study; all confirmed cases of (new and old) different rheumatological diseases on disease-modifying agents attended at the rheumatology clinic of Dhaka Medical College Hospital from January 2019 to December 2021 were enrolled. Result Among 489 cases, 90 (18.4%) patients had documented infections. The most common rheumatological diseases were systemic lupus erythematosus (28, 31.1%), ankylosing spondylitis (26, 28.8%), and rheumatoid arthritis (20, 22.2%). COVID-19 (28, 31.1%) was the most commonly occurring infection followed by urinary tract infection (14, 15.6%), fungal infection (12, 13.3%), herpes zoster (10, 11.1%), pulmonary tuberculosis (TB) (eight, 8.8%), latent TB (seven, 7.7%), community-acquired pneumonia (six, 6.6%), and sepsis (three, 3.3%). Infection was most prevalent among patients who received steroids of more than 10 mg per day (17, 18.8%) than those less than 10 mg steroid per day (six, 6.7%), Factors associated with infections were (odds ratio, 95% CI, p-value) underweight (2.3, [1.3-2.7], 0.001), anemia (1.8, [1.1-5.7], 0.01), neutropenia (1.6, [1.1-2.9], <0.002), hypoalbuminemia (3.1, [1.6-4.9], 0.001), hypovitaminosis D (1.9, [1.3-4.5], 0.001), high blood sugar (1.5, [1.1-5.3], 0.02), inadequate counseling of steroid side effect (1.7, [1.1-3.9], 0.03), prednisolone >10mg/day (2.2, [1.19-4.10], 0.001). Conclusion COVID-19 pneumonia, urinary tract infections, fungal infection, tuberculosis, herpes zoster, and community-acquired pneumonia were commonly occurring infections among patients receiving different immunosuppressive medications. Factors like poor nutritional status, presence of anemia, leucopenia, hypoalbuminemia, hyperglycemia, and hypovitaminosis D had a significant association with infection. Moreover, inadequate counseling of steroid side effects and history of daily intake of prednisolone (>10mg/day) were also significant factors associated with infection.

Increased prevalence of Staphylococcus aureus nasal carriage in rheumatoid arthritis patients with moderate/high disease activity

BACKGROUND

Staphylococcus aureus (S. aureus) nasal carriage is a well-known risk factor for surgical site infection (SSI) after total joint arthroplasty. This study aimed to compare the prevalence of S. aureus nasal carriage between patients with osteoarthritis (OA), a degenerative joint disease, and those with rheumatoid arthritis (RA), a chronic autoimmune inflammatory disease, who underwent total joint arthroplasty, and to investigate the influence of RA disease activity on nasal carriage rate.

METHODS

This retrospective study targeted 508 OA and 107 RA patients who underwent S. aureus nasal screening prior to primary total knee and/or hip arthroplasty. RA patients were divided into two groups based on disease activity: the remission/low disease activity (REM/LDA) group and the moderate/high disease activity (MDA/HDA) group. Factors associated with S. aureus nasal carriage were assessed with multivariate logistic regression models.

RESULTS

Of all 615 patients, 155 (25%) carried S. aureus in their nares. Compared to OA patients, RA patients had a significantly higher rate of S. aureus nasal carriage (24% vs. 33%, p = 0.049). Compared to the REM/LDA group (n = 39), the MDA/HDA group (n = 58) had a significantly higher rate of S. aureus nasal carriage (21% vs. 41%, p = 0.032). Multivariate analysis revealed that the MDA/HDA group, but not the REM/LDA group, had a significantly higher odds of S. aureus nasal carriage compared to the OA group (odds ratio: 2.76, 95% confidence interval: 1.07-7.12).

CONCLUSION

Preoperative nasal screening for S. aureus is beneficial, especially in RA patients with moderate/high disease activity.

Multimorbidity in rheumatoid arthritis: common mechanistic links and impact and challenges in routine clinical practice

Early identification and management of multimorbidity in patients with rheumatic and musculoskeletal diseases (RMDs), such as RA, is an integral, but often neglected, aspect of care. The prevalence and incidence of conditions such as osteoporosis, cardiovascular disease, pulmonary disease and malignancies, often co-existing with RA, continues to have significant implications for the management of this patient group. Multimorbidity in RMDs can be associated with inflammatory disease activity and target organ damage. Lifestyle factors, such as smoking and inactivity, further contribute to the burden of disease. Inflammation is the underlying factor, not just in RA but also many comorbidities. The current framework of a treat-to-target approach focuses on achieving early remission and inflammatory activity suppression. We describe how the comorbidity burden in people with RMDs impacts on disease outcome and treatment response. The importance of addressing comorbidity at an early stage and adopting a patient centred approach is critical in modern practice.

Glucocorticoid exposure and the risk of serious infections in rheumatoid arthritis: a marginal structural model application

OBJECTIVE

Observational studies have reported an increased risk of infections associated with glucocorticoids in RA, not supported by evidence from randomized controlled trials. Inappropriately accommodating time-varying exposure and confounding in observational studies might explain the conflicting results. Therefore, we compared the incidence of serious infections between different oral glucocorticoid dose patterns over three years in a prospective inception cohort, adjusting for time-varying confounders in marginal structural models.

METHODS

We included 9654 newly diagnosed RA patients from the Swedish Rheumatology Quality Register between 2007-2018 and followed them for three years after the first rheumatology visit. Follow-up was divided into 90-day periods. A mean oral prednisone daily dose was calculated for each period and categorized into 'no use', 'low' (≤10 mg/day) and 'high' (>10 mg/day) doses. The incidence of serious infections (hospitalization for infection) over follow-up periods was modelled by pooled logistic regression allowing separate effects for recent and past exposure.

RESULTS

An increased incidence of serious infections was associated with higher compared with lower doses and with more recent compared with past glucocorticoid exposure. Over 3 years of follow-up, the marginal structural models predicted one additional serious infection for every 83 individuals treated with low GC doses for the first 6 months, and for every 125 individuals treated with high GC doses for the first 3 months, compared with no GC use.

CONCLUSION

Our results broadly agree with previous observational studies showing a dose dependent increased risk of infection associated with (recent) use of oral glucocorticoids.

Association between glucocorticoid discontinuation and incidence of infection in older adults with rheumatoid arthritis: A retrospective cohort study

AIM

Old age and glucocorticoid (GC) use increase the susceptibility to infection in patients with rheumatoid arthritis (RA). Accordingly, we investigated whether GC discontinuation reduces the incidence of infection in older adults with RA and analyzed factors associated with GC discontinuation.

METHODS

Medical records of patients with RA aged ≥60 years were retrieved, and the association between GC use and the incidence of infection was investigated. The participants were divided into three groups: GC-continued, GC-discontinued, and non-GC; the incidence of infection was statistically analyzed. Furthermore, patient treatments and comorbidities were examined.

RESULTS

Among 389 patients with RA included in the study (n = 122, n = 126, and n = 141 in the GC-discontinued, GC-continued, and non-GC groups, respectively), 65 (16.7%) patients developed infection, and the incidence of infection was significantly higher in the GC-continued group than in the GC-discontinued (p = .021) and non-GC (p = .0003) groups; there was no significant difference between the non-GC and GC-discontinued groups (p = .659). The GC-discontinued group was more likely to require biologic use throughout the disease course than the other two groups. Comorbidities, especially malignancies (p = .004), were more common in the GC-continued group than in the GC-discontinued group (p = .007).

CONCLUSION

In patients with RA aged ≥60 years receiving GCs, GC discontinuation reduced the incidence of infection. Therefore, a further analysis of factors that help reduce GC use is necessary.

Conquering rheumatic diseases: are parasitic worms the answer?

Despite the introduction of novel treatment strategies, management of rheumatic disorders remains associated with substantial unmet clinical need. Of interest therefore, it has recently become apparent that there is a global inverse relationship between the incidence of such conditions and parasitic helminth infection, with striking examples involving rheumatoid arthritis (RA)/systemic lupus erythematosus (SLE) patients and filarial nematode worm infection in studies in India. Such findings reflect that helminths are master manipulators of the immune system, particularly in being able to modulate proinflammatory responses. The aim of this article is thus to consider findings to date on this exciting and intriguing research area to form an opinion on whether parasitic worms may be exploited to generate novel therapies for rheumatic diseases.

Long-term fracture risk in rheumatoid arthritis: impact of early sustained DAS28-remission and restored function, progressive erosive disease, body mass index, autoantibody positivity and glucocorticoids. A cohort study over 10 years

BACKGROUND

Risk of fragility fractures in patients with rheumatoid arthritis (RA) is increased. Disease-related inflammation in RA is associated with low Bone Mineral Density (BMD). However, effects of specific disease factors on fracture occurrence and whether or not such disease effects are independent of BMD are unknown.

METHODS

Analysis of fracture outcome in the prospective cohort of 2557 patients with early RA (67% women, mean age 58.1 ± 15.6 years) during an observation period of 10.6 ± 4.7 years. In 602 patients BMD was measured at baseline. The first major fragility fractures were considered. Kaplan-Meier and Cox regression analysis, adjusted for traditional factors, prior fracture, disease activity and period of inclusion, were used to estimate the risk of the outcome.

RESULTS

During follow-up fracture occurred in 352 patients (13.8%), a rate of 13/1000 p-y. A proportional risk reduction for the outcome was associated with Body Mass Index (BMI) at baseline, BMI ≥ 30 kg/m2, and over the first two years sustained Disease Activity Score (DAS28)-remission, DAS28-low disease activity and Health Assessment Questionnaire (HAQ) ≤ 0.5. The proportional risk elevation for fractures was associated with BMI ≤ 20 kg/m2, DAS28 at baseline, 6-month and at 1-year, cumulative DAS28 over the two years, RF, erosion score progression at 2-year, HAQ score and HAQ ≥ 1 at 6-month and 1-year and showed a trend for ACPA positivity. The estimated fracture risk was increased in users of glucocorticoids (GC), associated with a higher GC-dosage at follow-ups and a higher cumulative dosage over two years, independently of disease activity. With adjustment for BMD, there was no difference in fracture outcome by exposure to GC. The effects of a higher BMI, DAS28-remission and low HAQ ≤ 0.5 attained at 6-month of treatment initiation and sustained up to 2 years, RF, ACPA, and erosion score progression at 2-year were independent of low BMD.

CONCLUSIONS

This analysis supports importance of RA-specific risk factors in early RA for future major fragility fractures. Treat-to-target strategy and restored functional capacity in early RA-disease are important to prevent fractures. Autoantibody positivity, progressively erosive disease, and low weight could have additional value for personalized fracture preventive strategies in early RA.

Treatment with FAP-targeted zinc ferrite nanoparticles for rheumatoid arthritis by inducing endoplasmic reticulum stress and mitochondrial damage

Rheumatoid arthritis (RA) is a common chronic inflammatory disease characterized by the proliferation of fibroblast-like synoviocytes (FLS), pannus development, cartilage, and bone degradation, and, eventually, loss of joint function. Fibroblast activating protein (FAP) is a particular product of activated FLS and is highly prevalent in RA-derived fibroblast-like synoviocytes (RA-FLS). In this study, zinc ferrite nanoparticles (ZF-NPs) were engineered to target FAP⁺ (FAP positive) FLS. ZF-NPswere discovered to better target FAP⁺ FLS due to the surface alteration of FAP peptide and to enhance RA-FLS apoptosis by activating the endoplasmic reticulum stress (ERS) system via the PERK-ATF4-CHOP, IRE1-XBP1 pathway, and mitochondrial damage of RA-FLS. Treatment with ZF-NPs under the influence of an alternating magnetic field (AMF) can significantly amplify ERS and mitochondrial damage via the magnetocaloric effect. It was also observed in adjuvant-induced arthritis (AIA) mice that FAP-targeted ZF-NPs (FAP-ZF-NPs) could significantly suppress synovitis in vivo, inhibit synovial tissue angiogenesis, protect articular cartilage, and reduce M1 macrophage infiltration in synovium in AIA mice. Furthermore, treatment of AIA mice with FAP-ZF-NPs was found to be more promising in the presence of an AMF. These findings demonstrate the potential utility of FAP-ZF-NPs in the treatment of RA.

Individual patient data meta-analysis on continued use of glucocorticoids after their initiation as bridging therapy in patients with rheumatoid arthritis

OBJECTIVES

To investigate whether patients with rheumatoid arthritis (RA) can discontinue glucocorticoids (GC) after GC 'bridging' in the initial treatment step and to identify factors that may affect this.

METHODS

Data from 7 clinical trial arms (with 1653 patients) that included a GC bridging schedule, previously identified in a systematic literature search, were combined in an individual patient data meta-analysis. Outcomes were GC use (yes/no) at predefined time points (1/3/6/12/18 months after bridging had ended), cumulative GC dose and continuous (≥3 months) GC use after bridging had ended. Age, sex, ACPA status, initial GC dose, duration of bridging schedule, oral versus parenteral GC administration and initial co-treatment were univariably tested with each outcome.

RESULTS

The probability of using GC 1 month after bridging therapy had ended was 0.18, decreasing to 0.07 from 6 until 18 months after bridging had ended. The probability of continuous GC use after bridging had ended was 0.18 at 1 year and 0.30 at 2 years of follow-up. In oral GC bridging studies only, the probabilities of later and continuous GC use and the cumulative GC doses were higher compared to the combined analyses with also parenteral GC bridging studies included. A higher initial dose and a longer GC bridging schedule were associated with higher cumulative GC doses and more patients on GC at 18 months after bridging had ended.

CONCLUSIONS

Based on these RA clinical trial arms with an initial GC bridging schedule, the probability of subsequent ongoing GC use following bridging is low.

Tapering glucocorticoids and risk of flare in rheumatoid arthritis on biological disease-modifying antirheumatic drugs (bDMARDs)

INTRODUCTION

Glucocorticoids are still a mainstream of rheumatoid arthritis (RA) treatment. Reducing glucocorticoids should be attempted in all patients. However, choosing the right tapering strategy is challenging. The primary aim of our study is to determine the dose-response association between glucocorticoid tapering and risk of flare in RA.

METHODS

We conducted a case-crossover study to determine the factors associated to higher risk of flare in patients with RA. In case-crossover studies time-varying factors are assessed before events (hazard periods) and before control periods. We defined hazard periods as the 6 months immediately preceding flares of RA. Control periods were the 6 months prior to visits without flare. Exposure of interest was the tapering of glucocorticoids to various doses.

RESULTS

508 patients with RA were included in the study and 267 (52.5%) had at least a flare and served as the case-crossover study population. 1545 visits were available for analysis and 345 (22.3%) flares were recorded. Discontinuation of glucocorticoids (ie, tapering to doses of 0 mg/day) and tapering to 0-2.5 mg/day was associated with higher risk of flare (adjusted OR (aOR) of 1.45, 95% CI: 1.13 to 2.24 and aOR of 1.37; 95% CI: 1.06 to 2.01, respectively). Tapering to doses >2.5 mg/day was not associated with significantly higher risk of flare.

CONCLUSIONS

We found that tapering to doses of >2.5 mg/day was generally effective in terms of risk of flare. Flare risk was higher when glucocorticoids were tapered to doses ≤2.5 mg/day. Our study might help design new tapering strategies in patients with RA on biological disease-modifying antirheumatic drugs.

Efficacy, duration of use and safety of glucocorticoids: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis

This systematic literature review (SLR) regarding the efficacy, duration of use and safety of glucocorticoids (GCs), was performed to inform the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis (RA). Studies on GC efficacy were identified from a separate search on the efficacy of disease-modifying antirheumatic drugs (DMARDs). A combined search was performed for the duration of use and safety of GCs in RA patients. Dose-defined and time-defined GC treatment of any dose and duration (excluding intra-articular GCs) prescribed in combination with other DMARDs were considered. Results are presented descriptively. Two included studies confirmed the efficacy of GC bridging as initial therapy, with equal efficacy after 2 years of initial doses of 30 mg/day compared with 60 mg/day prednisone. Based on a recently performed SLR, in clinical trials most patients starting initial GC bridging are able to stop GCs within 12 (22% patients continued on GCs) to 24 months (10% patients continued on GCs). The safety search included 12 RCTs and 21 observational studies. Well-known safety risks of GC use were confirmed, including an increased risk of osteoporotic fractures, serious infections, diabetes and mortality. Data on cardiovascular outcomes were Inconsistent. Overall, safety risks increased with increasing dose and/or duration, but evidence on which dose is safe was conflicting. In conclusion, this SLR has confirmed the efficacy of GCs in the treatment of RA. In clinical trials, most patients have shown to be able to stop GCs within 12-24 months. Well-known safety risks of GC use have been confirmed, but with heterogeneity between studies.

Bidirectional two-sample Mendelian randomization study of causality between rheumatoid arthritis and myocardial infarction

Background

Epidemiological evidence suggests an association between rheumatoid arthritis (RA) and myocardial infarction (MI). However, causality remains uncertain. Therefore, this study aimed to explore the causal association between RA and MI.

Methods

Using publicly available genome-wide association study summary datasets, bidirectional two-sample Mendelian randomization (TSMR) was performed using inverse-variance weighted (IVW), weighted median, MR-Egger regression, simple mode, and weighted mode methods.

Results

The MR results for the causal effect of RA on MI (IVW, odds ratio [OR] = 1.041, 95% confidence interval [CI]: 1.007-1.076, P = 0.017; weighted median, OR = 1.027, 95% CI: 1.006-1.049, P = 0.012) supported a causal association between genetic susceptibility to RA and an increased risk of MI. MR results for the causal effect of MI on RA (IVW, OR = 1.012, 95% CI: 0.807-1.268, P = 0.921; weighted median, OR = 1.069, 95% CI: 0.855-1.338, P = 0.556) indicated that there was no causal association between genetic susceptibility to MI and an increased risk of RA.

Conclusion

Bidirectional TSMR analysis supports a causal association between genetic susceptibility to RA and an increased risk of MI but does not support a causal association between genetic susceptibility to MI and an increased risk of RA.

Optimizing Medication Use in Older Adults With Rheumatic Musculoskeletal Diseases: Deprescribing as an Approach When Less May Be More

The world population is aging, and the rheumatology workforce must be prepared to care for medically complex older adults. We can learn from our colleagues and experts in geriatrics about how to best manage multimorbidity, polypharmacy, geriatric syndromes, and shifting priorities of older adults in the context of delivering care for rheumatic and musculoskeletal diseases (RMDs). Polypharmacy, a common occurrence in an aging population with multimorbidity, affects half of older adults with RMDs and is associated with increased risk of morbidity and mortality. In addition, potentially inappropriate medications that should be avoided under most circumstances is common in the RMD population. In recent years, deprescribing, known as the process of tapering, stopping, discontinuing, or withdrawing drugs, has been introduced as an approach to improve appropriate medication use among older adults and the outcomes that are important to them. As the rheumatology patient population ages globally, it is imperative to understand the burden of polypharmacy and the potential of deprescribing to improve medication use in older adults with RMDs. We encourage the rheumatology community to implement geriatric principles, when possible, as we move toward becoming an age-friendly health care specialty.

Systemic lupus erythematosus and the risk of cardiovascular diseases: A two-sample Mendelian randomization study

Background

Previous observational studies have suggested that the causal role of systemic lupus erythematosus (SLE) in the risk of cardiovascular diseases (CVDs) remained inconsistent. In this study, we aimed to investigate the causal relationship between SLE and CVDs by two-sample Mendelian randomization (MR) analysis.

Methods

Genetic instruments for SLE were obtained from a public genome-wide association study (GWAS) with 4,036 patients with SLE and 6,959 controls. Summary statistical data for CVDs, including coronary artery disease (CAD), myocardial infarction (MI), atrial fibrillation (AF), ischemic stroke (IS), and its subtypes, were identified from other available GWAS meta-analyses. The inverse-variance weighted (IVW) method was used as the primary method to estimate the causal effect. The simple- and weighted-median method, MR-Egger method, and MR pleiotropy residual sum and outlier (MR-PRESSO) were provided as a supplement to the IVW method. Besides, we performed sensitivity analyses, including Cochran's Q test, MR-Egger intercept test, and leave-one-out analysis, to evaluate the robustness of the results.

Results

A total of 15 single-nucleotide polymorphisms (SNPs) were identified after excluding linkage disequilibrium (LD) and potential confounding factors. According to the IVW results, our MR study indicated that genetically predicted SLE was not causally connected with the risk of CVDs [CAD: odds ratio (OR) = 1.005, 95% confidence interval (CI) = 0.986–1.024, p-value = 0.619; MI: OR = 1.002, 95% CI = 0.982–1.023, p-value = 0.854; AF: OR = 0.998, 95% CI = 0.982–1.014, p-value = 0.795; IS: OR = 1.006, 95% CI = 0.984–1.028, p-value = 0.621; cardioembolic stroke (CES): OR = 0.992, 95% CI = 0.949–1.036, p-value = 0.707; small vessel stroke (SVS): OR = 1.014, 95% CI = 0.964–1.067, p-value = 0.589; large artery stroke (LAS): OR = 1.030, 95% CI = 0.968–1.096, p-value = 0.352]. Analogical findings could be observed in supplementary MR methods. Sensitivity analyses suggested that the causal estimates were robust.

Conclusion

Our two-sample MR analysis provided no evidence that genetically determined SLE was causally associated with the risk of CVDs.

The Effect of TNF-α on CHD and the Relationship between TNF-α Antagonist and CHD in Rheumatoid Arthritis: A Systematic Review

Tumor necrosis factor-alpha (TNF-α) plays an important role in coronary heart disease (CHD), a chronic inflammatory process. Meanwhile, this pro-inflammatory factor is also involved in the pathogenesis of autoimmune diseases such as rheumatoid arthritis (RA). Patients with RA correspond to a higher risk of CHD. TNF-α antagonist, one of the main treatments for RA, may reduce the risk of CHD in patients with RA. This review summarizes the pathogenesis of TNF-α in CHD and discusses the relationship between TNF-α antagonist and CHD in patients with RA.

Assessment of Cardiac Risk in Women with Autoimmune Disease

PURPOSE OF REVIEW

The purpose of our review was to evaluate current standards in clinical practice in determining overall cardiac risk in female patients with chronic rheumatologic diseases. We hoped to not only summarize known cardiac manifestations of various chronic rheumatologic diseases but also determine the effectiveness of new risk scores in determining cardiac risk in this patient population.

RECENT FINDINGS

Chronic rheumatologic diseases have been associated with various cardiac manifestations for some time, with initial studies involving risk of coronary artery disease (CAD) in rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). However, recent studies have shown numerous other cardiac manifestations associated with these and other chronic rheumatologic diseases. Risk scores have been used for several decades to help determine overall cardiac risk in the general population, but these risk scores have notoriously underestimated the risk of cardiac disease in woman and in patients with chronic rheumatologic diseases. These diseases, often with a female predominance, can impact long-term mortality and have devastating consequences if not monitored and treated appropriately. Thus, new risk scores have been developed over the last several years to help improve detection and awareness of cardiac disease in these patients. Novel modified risk scores have found some success at improving the detection of cardiac disease in patients with chronic rheumatologic diseases. Further studies looking at these risk scores need to determine the accuracy of these scores and where they fall short. With the advent of advanced imaging technologies, future risk scores may involve certain imaging-based markers to help guide accurate risk determination.

Systematic literature review of observational cohorts and clinical trials into the success rate of glucocorticoid discontinuation after their use as bridging therapy in patients with rheumatoid arthritis

OBJECTIVE

To investigate the success rate of glucocorticoid (GC) discontinuation during follow-up in observational cohorts and clinical trials using temporary GC as part of initial therapy ('bridging') in newly diagnosed patients with rheumatoid arthritis (RA).

METHODS

Systematic literature searches were conducted to identify observational cohorts and clinical trials including patients with RA treated with initial GC bridging therapy, defined as discontinuation of GC within 1 year. Patient percentages still using GC were considered the reverse of successful discontinuation. Random effects meta-analyses were performed stratified by time point.

RESULTS

The scoping literature search for observational cohort studies could not identify studies answering the research question. The literature search for clinical trials identified 7160 abstracts, resulting in 10 included studies, with varying type and dose of GC and varying tapering schedules, of which 4 reported sufficient data on GC discontinuation or use after the bridging phase. The pooled proportion of patients who were still or again using GC was 22% (95% CI 8% to 37%, based on four trials) at 12 months and 10% at 24 months (95% CI -1 to 22, based on two trials). Heterogeneity was substantial (I²≥65%).

CONCLUSION

The success rate of GC discontinuation after bridging as part of initial treatment of RA has been described in a limited number of studies. Reports on observational cohorts did not answer the research question. In clinical trials, protocolised discontinuation was mostly successful, although 22% of the patients who started GC bridging therapy still or again used GC at 12 months, and 10% at 24 months.

Managing Cardiovascular Risk in Patients with Rheumatic Disease

Individuals with rheumatoid arthritis, systemic lupus erythematosus, or gout have increased risk of cardiovascular disease (CVD) compared with the general population. This risk relates to a combination of traditional cardiovascular risk factors and disease-specific factors. Screening for CVD is important because CVD contributes to significant morbidity and mortality. Management includes tight control of disease activity to reduce inflammation, but with care to minimize use of nonsteroidal anti-inflammatory drugs and prolonged courses of high-dose corticosteroids. Traditional cardiovascular risk factors should be managed with a combination of lifestyle interventions and pharmacotherapy. The decision to start antihypertensive and lipid-lowering therapy should be based on individual CVD risk.

Factors affecting patient satisfaction related to cost and treatment effectiveness in rheumatoid arthritis: results from the multicenter observational cohort study, FRANK Registry

Background

To further improve rheumatoid arthritis (RA) treatment, it is necessary to understand each RA patient’s satisfaction and to identify the factors affecting their satisfaction. Despite the rise in medical costs for RA, little is known about the factors that influence patient satisfaction with the cost of treatment in RA patients.

Methods

This is a multicenter observational study of Japanese RA patients from the FRANK Registry with data analyzed from March 2017 to August 2020. We collected data on demographic characteristics, clinical data, quality of life which was evaluated using the EuroQol 5-dimensional questionnaire (EQ5D), and patient satisfaction. The four categories of patient satisfaction were evaluated individually (i.e., cost, treatment efficacy, activities of daily living [ADL], and global treatment satisfaction). We analyzed the factors that affected each patient’s satisfaction, such as age, sex, EQ5D, disease duration, disease activity, and treatment.

Results

This study included 2235 RA outpatients (406 males, 1829 females). In RA patients, “very satisfied” and “satisfied” were given for nearly half of each satisfaction aspect (cost 49%; efficacy 72%; ADL 58%; global treatment 66%) at the time of the initial registration. To investigate the factors influencing each satisfaction, multivariate analysis has revealed that the use of b/tsDMARDs increased satisfaction of treatment effect (odds ratio [OR] 0.66) and ADL (OR 0.78) but decreased cost satisfaction (OR 2.21). Age (50–64 years; OR 0.91; 65–74 years, 0.55: ≥ 75 years, 0.35), female (OR 0.81), and history of musculoskeletal surgery (OR 0.60) all increased cost satisfaction. Patients with lower disease activity and higher EQ5D scores had higher levels of satisfaction in all areas.

Conclusions

In this study, patient satisfaction in terms of cost, treatment effect, ADL, and overall treatment was generally higher, but some patients were dissatisfied. The cost of satisfaction increased with age and a history of musculoskeletal surgery, while it decreased with a lower EQ5D score and the use of b/tsDMARDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02746-5.

Arthritis is associated with an increased risk of incident diabetes in Chinese adults: A nationwide cohort study and updated meta-analysis

AIMS

To prospectively examine the association between arthritis and type 2 diabetes (T2D) in the Chinese population and confirm this association through a comprehensive meta-analysis of cohort studies.

METERIALS AND METHODS

Data were from the China Health and Retirement Longitudinal Study which was started in 2011-2013 and followed up in 2013-2014 and 2015-2016. Arthritis was defined as self-reported physician diagnosis at baseline, and incident T2D was determined by self-reported physician diagnosis, fasting blood glucose ≥7.0 mmol/L or glycosylated haemoglobin ≥6.5% during the follow-ups. Cox proportional hazards regression models were used to assess the association between arthritis and risk for T2D. A meta-analysis was conducted to pool our effect estimate and those from other cohort studies using a random-effects model.

RESULTS

Eleven thousand four hundred and eight participants (47.9% men; mean age: 59.3 years) were included in final analyses. During a 4-year follow-up, 981 participants reported incident T2D. Compared with individuals without arthritis, those with arthritis at baseline had an 18% higher risk for incident T2D (multivariable-adjusted hazard ratio: 1.18; 95% confidence interval: 1.04, 1.34). In the meta-analysis of 13 cohort studies including ours, a total of 2,473,514 participants were included with 121,851 incident diabetes. The pooling HR was 1.32 (95% CI: 1.21, 1.44) for the association between arthritis and diabetes.

CONCLUSION

Arthritis was associated with an increased risk of incident diabetes in Chinese adults, and the positive association was confirmed in the meta-analysis of cohort studies. Our work can inform clinical trials to assess the effectiveness of arthritis treatments in reducing risk of diabetes.

Sarcopenia May Be a Risk Factor for Osteoporosis in Chinese Patients with Rheumatoid Arthritis

Purpose

Osteoporosis (OP) has been classically considered a co-morbidity of rheumatoid arthritis (RA). This investigation determined the clinical significance of sarcopenia in patients with RA combined with OP or whether sarcopenia influences RA when combined with OP.

Materials and Methods

Data pertaining to the duration of RA, C-reactive protein (CRP) level, and erythrocyte sedimentation rate (ESR) were collected from 549 RA cases and 158 healthy individuals. Disease activity score at 28 joints (DAS28), the body mass index (BMI), health assessment questionnaire (HAQ), bone mineral density (BMD), and Sharp score were compared between the 2 groups.

Results

The prevalence of OP (33.3% vs 12.7%, χ²= 69.992, P < 0.0001) and sarcopenia (61.7% vs 9.0%, χ²= 135.336, P < 0.01) was greater in patients with RA than in healthy controls. RA patients with sarcopenia had a higher incidence of OP at all measured sites than RA patients without sarcopenia (all P < 0.0001), and the incidence of OP was significantly higher than in patients with mild-to-moderate or severe RA without sarcopenia (P < 0.0001). Differences in age, gender, course of disease, CRP level, ESR, DAS28, BMI, HAQ, BMD, and Sharp score were statistically different between the RA with or without sarcopenia groups (P < 0.01). The incidence of OP and sarcopenia was higher in RA patients treated than not treated with glucocorticoids [GCs] (36.4% vs 29.3%, P < 0.05 and 66.1% vs 56.0%, respectively; P < 0.05). Logistic regression showed that the risk factors for OP in RA individuals were female (OR, 14.671; 95% CI, 6.877–31.300; P < 0.0001), age (OR, 1.100; 95% CI, 1.076–1.124; P < 0.0001), and sarcopenia (OR, 3.561; 95% CI, 2.214–5.726; P < 0.0001).

Conclusion

OP and sarcopenia are common in RA patients. Sarcopenia may be a risk factor for OP occurrence in Chinese patients with RA.

RHEUMATOID ARTHRITIS AS A PREDISPOSING FACTOR FOR INCREASED RISK OF DIABETES MELLITUS INCIDENCE

OBJECTIVE

The aim: Recent advances in diabetic mellitus (DM) care are focusing emphasis on comorbidities including rheumatoid arthritis (RA). The goal of this study is to determine the relationship between RA and diabetes as a risk factor.

PATIENTS AND METHODS

Materials and methods: Participants whose diagnosis of RA was confirmed by rheumatologists were recruited into a cross-sectional observational cohort using data from government and private clinics. Participants filled out detailed questionnaires. We included patients with DM and combined DM and RA who was diagnosed with both conditions by specialists between (October 2021 to April 2022) in Al Kut city, Iraq.

RESULTS

Results: Our finding shows no difference between the two groups DM and DM+RA in age, BMI, and smoking. However, the health status represented by hospitalization was more frequent in the DM+RA group. The inflammatory pathway in RA also increases the incidence of DM where we show an increase in the ESR in the DM+RA group. Interestingly Glycated hemoglobin (Hb a1c) indicator of DM was significantly increased in DM+RA compared to the DM group.

CONCLUSION

Conclusions: In conclusion, RA is linked to an increased chance of developing diabetes. This data backs up the theory that inflammatory pathways play a role in diabetes development.

Risk of Serious Infection With Low-dose Glucocorticoids in Patients With Rheumatoid Arthritis: An Instrumental Variable Analysis

BACKGROUND

Low-dose glucocorticoids are commonly used in the treatment of rheumatoid arthritis (RA). Observational studies have found an increased risk of serious infection associated with low-dose glucocorticoids, but concerns about residual confounding remain.

METHODS

We identified adults with RA on stable immunomodulatory therapy for >6 months receiving no glucocorticoids or ≤5 mg/day using Medicare data from 2006 to 2015. We used provider preference for glucocorticoids as an instrumental variable (IV) to assess associations between low-dose glucocorticoid use and the risk of infection requiring hospitalization using a cause-specific proportional hazards model.

RESULTS

We identified 163,603 qualifying treatment episodes among 120,656 patients. Glucocorticoids ≤5 mg/day were used by 25,373/81,802 (31.0%) of patients seen by a rheumatologist with low provider preference for glucocorticoids and by 36,087/81,801 (44.1%) of patients seen by a rheumatologist with high provider preference for glucocorticoids (adjusted odds ratio 1.81, 95% confidence interval 1.77, 1.84 for association between provider preference and glucocorticoids). Chronic obstructive pulmonary disease, opioids, antibiotics, previous emergency department visits, hospitalizations, and infections requiring hospitalization infections were unbalanced with regard to exposure but not to the IV. The incidence of infection requiring hospitalization was 8.0/100 person-years among patients unexposed to glucocorticoids versus 11.7/100 person-years among those exposed. The association between glucocorticoids and infection requiring hospitalization from IV analysis (hazard ratio 1.26 [1.02-1.56]) was similar to results from a standard multivariable model (hazard ratio 1.24 [1.21-1.28]).

CONCLUSIONS

Among patients with RA on stable immunomodulatory therapy, IV analysis based on provider preference demonstrated an increased risk of infection requiring hospitalization associated with low-dose glucocorticoids, similar to a traditional analysis.

Long-term outcomes after coronary artery bypass surgery in patients with rheumatoid arthritis

OBJECTIVE

To investigate the long-term outcomes of coronary artery bypass grafting surgery (CABG) in patients with rheumatoid arthritis (RA).

METHODS

Patients with RA (n = 378) were retrospectively compared to patients without RA (n = 7560), all treated with CABG in a multicentre, population-based cohort register study in Finland. The outcomes were studied with propensity score-matching adjustment for baseline features. The median follow-up was 9.7 years.

RESULTS

Diagnosis of RA was associated with an increased risk of mortality after CABG compared to patients without RA (HR 1.50; CI 1.28-1.77; p < .0001). In addition, patients with RA were in higher risk of myocardial infarction during the follow-up period (HR 1.61; CI 1.28-2.04; p < .0001). Cumulative rate of repeated revascularization after CABG was 14.4% in RA patients and 12.0% in control patients (p = .060). Duration of RA before CABG (p = .011) and preoperative corticosteroid usage in RA (p = .041) were independently associated with higher mortality after CABG. There were no differences between the study groups in 30-d mortality or in the post-operative usage of cardiovascular medications.

CONCLUSIONS

RA is independently associated with worse prognosis in coronary artery disease treated with CABG. Preoperative corticosteroid use and longer RA disease duration are additional risk factors for mortality.Key messagesPatients with rheumatoid arthritis (RA) have impaired long-term outcomes after coronary artery bypass surgery (CABG).Glucocorticoid use before CABG and duration of RA are associated with higher mortality.Special attention should be paid in secondary prevention of cardiovascular disease in RA patients after CABG.

The Potential Protective Effect of Iridoid Glycosides Isolated From Osmanthus fragrans Seeds Against the Development of Immune Liver Injury in Mice

Objective: The iridoid glycosides were extracted and separated from Osmanthus fragrans seeds, and the potential protective effect of Osmanthus fragrans seed extract on concanavalin A-induced immune liver injury in mice was studied.

Methods:Osmanthus fragrans seeds were extracted by 95% ethanol reflux. Then, the iridoid glycosides were enriched by extraction refined through petroleum ether (60°C–90°C), ethyl acetate, and water-saturated n-butanol in sequence, so as to purify the n-butanol part (Osmanthus fragrans seed’s n-butanol extraction, OFSN) by macroporous resin. Specnuezhenide and Nuezhenoside G13 were used as the reference substances to determine the concentration of iridoid glycosides by HPLC. On this basis, a mouse immune liver injury model was established by tail intravenous concanavalin A (20 mg/kg); the contents of serum ALT, AST, IFN-γ, and TNF-α and the contents of liver tissue MDA and SOD were determined; the pathological changes of the liver by HE staining were observed; and the expression levels of p38MAPK and p-p38mapk in liver tissue were detected by WB.

Results: The linearity, precision, repeatability, recovery, and stability of HPLC all met the requirements by validating with the methodology. The contents of Specnuezhenide and Nuezhenoside G13 in the n-butanol extracts were 39.20% and 39.88%, respectively. Actually, their contents can reach up to 82.56% and 87.9% after being purified by macroporous resin. The results of animal experiments show that OFSN could significantly reduce the liver and spleen index, reduce the ALT and AST contents in plasma and the MDA content in liver tissue, and then increase the SOD content. Besides, OFSN could also reduce the plasma IFN-γ and TNF-α levels. The HE staining result indicates that the pathological changes in the liver tissues of mice treated with OFSN are alleviated to different degrees while the WB result suggests that OFSN could significantly inhibit the expression of p-p38mapk.

Conclusion:Osmanthus fragrans seeds are rich in iridoid glycosides, which has a good protective effect on mouse immune liver injury caused by concanavalin A. The mechanism may be related to inhibiting the phosphorylation of p38MAPK, inhibiting the release of inflammatory mediators, improving the antioxidant capacity of liver cells, and weakening the occurrence of lipid peroxidation.

Natural and iatrogenic ocular manifestations of rheumatoid arthritis: a systematic review

Purpose

To provide an overview of the ocular features of rheumatoid arthritis (RA) and of the ophthalmic adverse drug reactions (ADRs) that may be associated with the administration of antirheumatic drugs.

Methods

A systematic literature search was performed using the PubMed, MEDLINE, and EMBASE databases. In addition, a cohort of 489 RA patients who attended the Authors’ departments were examined.

Results

Keratoconjunctivitis sicca, episcleritis, scleritis, peripheral ulcerative keratitis (PUK), and anterior uveitis were diagnosed in 29%, 6%, 5%, 2%, and 10%, respectively, of the mentioned cohort. Ocular ADRs to non-steroidal anti-inflammatory drugs are rarely reported and include subconjunctival hemorrhages and hemorrhagic retinopathy. In patients taking indomethacin, whorl-like corneal deposits and pigmentary retinopathy have been observed. Glucocorticoids are frequently responsible for posterior subcapsular cataracts and open-angle glaucoma. Methotrexate, the prototype of disease-modifying antirheumatic drugs (DMARDs), has been associated with the onset of ischemic optic neuropathy, retinal cotton-wool spots, and orbital non-Hodgkin’s lymphoma. Mild cystoid macular edema and punctate keratitis in patients treated with leflunomide have been occasionally reported. The most frequently occurring ADR of hydroxychloroquine is vortex keratopathy, which may progress to “bull’s eye” maculopathy. Patients taking tofacitinib, a synthetic DMARD, more frequently suffer herpes zoster virus (HZV) reactivation, including ophthalmic HZ. Tumor necrosis factor inhibitors have been associated with the paradoxical onset or recurrence of uveitis or sarcoidosis, as well as optic neuritis, demyelinating optic neuropathy, chiasmopathy, and oculomotor palsy. Recurrent episodes of PUK, multiple cotton-wool spots, and retinal hemorrhages have occasionally been reported in patients given tocilizumab, that may also be associated with HZV reactivation, possibly involving the eye. Finally, rituximab, an anti-CD20 monoclonal antibody, has rarely been associated with necrotizing scleritis, macular edema, and visual impairment.

Conclusion

The level of evidence for most of the drug reactions described herein is restricted to the “likely” or “possible” rather than to the “certain” category. However, the lack of biomarkers indicative of the potential risk of ocular ADRs hinders their prevention and emphasizes the need for an accurate risk vs. benefit assessment of these therapies for each patient.

Prevalence and Extent of Subclinical Atherosclerosis and Associated Cardiovascular Risk Factors in Adult Patients With Psoriatic Arthritis: A Systematic Review

Psoriatic arthritis (PsA) is a chronic T cell-mediated inflammatory condition affecting a considerable proportion of psoriasis (PSO) patients and a small segment of the general population. Recent studies have shown that patients with PsA are prone to premature atherosclerosis and are at an increased risk of cardiovascular disease (CVD) events, but the extent and prevalence of this are unknown. Our objective was to evaluate the prevalence and extent of subclinical atherosclerosis by measuring the intima-media thickness (IMT) of arteries in adult patients with PsA, as well as identify cardiovascular (CV) risk factors associated with PsA. An extensive literature search was conducted using PubMed as our main database. The articles exploring the association between PsA and subclinical atherosclerosis were included. We also searched other databases like MEDLINE and PubMed Central (PMC). A total of 2,561 studies published between 2005-2021 were obtained by searching the databases, and after the screening process, a total of nine studies were included for review and an additional 22 studies for comparison and backup evidence. As for results, our review included a total of 542 patients with PsA from nine different studies. All the reviewed studies showed a significant association between subclinical atherosclerosis and PsA, as endothelial functions were found to be impaired in PsA patients as deduced by measuring the carotid intima-media thickness (CIMT). PsA patients exhibited greater IMT than healthy controls. Increased IMT independently correlated with parameters of disease activity and conventional risk factors of atherosclerosis. An increased prevalence of CV risk factors such as hypertension, diabetes, obesity, and metabolic syndrome was also found in PsA patients.

Mortality in Korean Patients With Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the abnormal immune system causes arthritis. We reviewed previous studies about the mortality and causes of death in Korean patients with RA. Also, we discussed the association between comorbidities and mortality in Korean patients with RA. In Korea, a few epidemiologic studies reporting mortality rates in patients with RA have been conducted using large databases. According to these data sources, the estimated mortality rate of Korean patients with RA from 1.29% to 1.65%. Despite substantial improvements in RA management, the mortality rate of patients with RA remains higher than that of the general population. Also, the most common cause of death was malignancy, and respiratory disease and cardiovascular disease followed. The malignancy-specific mortality rate of patient with RA was not higher than that of the general population; however, several causes of death, such as respiratory disease and infections, were associated with a higher mortality rate among patients with RA than among the general population. Therefore, to increase the survival rate of patients with RA, attention should be paid to the management of comorbidities as well as to the RA itself.

Cardiovascular risk comorbidities in rheumatoid arthritis patients and the use of anti-rheumatic drugs: a cross-sectional real-life study

BACKGROUND

Rheumatoid arthritis (RA) is a common autoimmune systemic inflammatory disease. In addition to joint involvement, RA patients frequently have other comorbidities, such as cardiovascular diseases. Drugs used for RA treatment may increase or decrease the risk of a cardiovascular event. This study aims to analyze cardiovascular risk comorbidities in patients with RA and the correlation with the use of anti-rheumatic drugs.

METHODS

Cross-sectional study conducted based on the real-life rheumatoid arthritis study database - REAL, a prospective observational cohort study. Associations between the use of anti-rheumatic drugs and the presence of comorbidities were represented by their prevalence ratio and evaluated using the Chi-square or Fisher's Exact tests.

RESULTS

We assessed 1116 patients, 89.4% women, mean age of 55.15 years and predominance of seropositive disease. 63.3% had some cardiovascular comorbidity, predominantly hypertension (49.9%). The use of glucocorticoids was observed in 47.4% of patients and there was a significant tendency of lower use of these drugs in the presence of dyslipidemia (PR: 0.790; p = 0.007). We observed that the presence of cardiovascular comorbidities was associated with higher use of bDMARDs (PR:1.147; p = 0.003).

CONCLUSIONS

The presence of cardiovascular risk comorbidities was confirmed to be higher in RA patients. Different treatment strategies using less glucocorticoids in the presence of dyslipidemia and more common use of bDMARDs in patients with cardiovascular comorbidities suggest that rheumatologists are aware of the potential influence of the DMARDs in the risk of cardiovascular event. Reinforcing these results, we highlight the need for a better baseline assessment to guide the choice of anti-rheumatic drugs in RA patients who have comorbidities.

Gastrointestinal perforations in patients with rheumatoid arthritis treated with biological disease-modifying antirheumatic drugs in Sweden: a nationwide cohort study

OBJECTIVES

To compare incidence rates of gastrointestinal (GI) perforations between patients with RA and the general population, and between patients treated with tumour necrosis factor inhibitors (TNFi) and non-TNFi biologics.

METHODS

In this nationwide cohort study, a total of 63 532 patients with RA, with 26 050 biological treatment episodes (TNFi, rituximab, abatacept or tocilizumab) and 76 304 general population controls, were followed between 2009 and 2017 until the first outcome event. The main outcome was hospitalisation or death due to lower GI perforations, identified according to a prespecified list of ICD-10 (International Classification of Diseases, 10th revision) codes. Inverse probability of treatment weighting was used for adjustment.

RESULTS

The sex-standardised and age-standardised incidence rates of lower GI perforations were 1.1 (95% CI 1.0 to 1.3) events per 1000 person-years among general population controls, 1.6 (1.5-1.7) among bionaïve patients and ranged from 1.8 (1.4-3.6) (TNFi) to 4.5 (2.7-10.4) (tocilizumab) among biologics-treated patients. After adjustment for glucocorticoid use, the risk in bionaïve, TNFi-treated, abatacept-treated or rituximab-treated patients with RA was no longer different from the general population, while for tocilizumab it remained significantly higher. Comparing tocilizumab to TNFi, the adjusted HR for lower GI perforations was 2.2 (1.3-3.8), corresponding to one additional GI perforation per 451 patient-years treated with tocilizumab instead of TNFi.

CONCLUSION

Tocilizumab was associated with a higher risk of lower GI perforations compared with alternative biologics. In absolute numbers, the risk remained low on all biologics commonly used to treat RA, but the accumulated evidence across settings and outcome definitions supports that this risk should be considered in treatment guidelines for RA.

Osteoporosis and fractures in rheumatoid arthritis

PURPOSE OF REVIEW

Rheumatoid arthritis (RA) is associated with increased risk for osteoporotic fracture. We highlight RA-specific risk factors for bone mineral density (BMD) loss and fractures and considerations regarding the diagnosis and treatment of osteoporosis in patients with RA.

RECENT FINDINGS

Anticitrullinated protein antibody (ACPA) positivity, although associated with low BMD in early RA, is not associated with accelerated BMD loss over time when compared to ACPA negative individuals. Studies have found reduced BMD in individuals on low doses of glucocorticoids (GCs). Poor functional status and frailty are additional important risk factors for low BMD and fractures. Heightened fracture risk in RA may be mitigated by tight disease control, and biologic therapies are associated with more stable BMD compared to nonbiologic therapies. Evidence-based guidelines specific for treating osteoporosis in patients with RA do not exist. Thus, treatment decisions are based on general osteoporosis guidelines, taking into account additional RA-specific risk factors.

SUMMARY

Recent studies have advanced knowledge of RA-specific risk factors for BMD loss and fractures. Future studies applying these findings to modify established fracture risk algorithms as well as evaluating osteoporosis treatments in RA cohorts are needed to reduce the risk of disabling fractures in these patients.

Glucocorticoid and opioid use in rheumatoid arthritis management

PURPOSE OF REVIEW

Glucocorticoids and opioids are longstanding, common treatments for rheumatoid arthritis (RA) symptoms. High-quality clinical trials have established that glucocorticoids improve outcomes in RA, but debate continues as to whether their benefits outweigh their risks. We reviewed recent studies on patterns of glucocorticoid and opioid prescribing in RA, and associated harms.

RECENT FINDINGS

At present, a large proportion of RA patients remain on glucocorticoids and/or opioids long-term. Likelihood and risk of both glucocorticoid and opioid exposure vary across the population, and are influenced by provider factors. Opioids are also associated with delays in disease-modifying treatment initiation. Recent evidence increasingly demonstrates toxicity associated with even low-dose glucocorticoids (≤7.5 mg/day). Up to two-thirds of RA patients may be able to discontinue chronic low-dose glucocorticoids without flare or adrenal insufficiency. These new data have led to changes in clinical practice guidelines for glucocorticoid use in RA.

SUMMARY

Although low-dose and short-term glucocorticoid use is extremely common and effective in RA management, increasing evidence of toxicity has led experts to begin recommending that such exposure be minimized. Despite a lack of data to suggest opioids improve RA disease activity, they are used commonly, continued long-term, and associated with delayed effective therapy.

Glucocorticoid use is associated with an increased risk of hypertension

OBJECTIVES

Patients with RA are frequently treated with glucocorticoids (GCs), but evidence is conflicting about whether GCs are associated with hypertension. The aim of this study was to determine whether GCs are associated with incident hypertension in patients with RA.

METHODS

A retrospective cohort of patients with incident RA and without hypertension was identified from UK primary care electronic medical records (Clinical Practice Research Datalink). GC prescriptions were used to determine time-varying GC use, dose and cumulative dose, with a 3 month attribution window. Hypertension was identified through either: blood pressure measurements >140/90 mmHg, or antihypertensive prescriptions and a Read code for hypertension. Unadjusted and adjusted Cox proportional hazards regression models were fitted to determine whether there was an association between GC use and incident hypertension.

RESULTS

There were 17 760 patients in the cohort. A total of 7421 (42%) were prescribed GCs during follow-up. The incident rate of hypertension was 64.1 per 1000 person years (95% CI: 62.5, 65.7). The Cox proportional hazards model indicated that recent GC use was associated with a 17% increased hazard of hypertension (hazard ratio 1.17; 95% CI: 1.10, 1.24). When categorized by dose, only doses above 7.5 mg were significantly associated with hypertension. Cumulative dose did not indicate a clear pattern.

CONCLUSION

Recent GC use was associated with incident hypertension in patients with RA, in particular doses ≥7.5 mg were associated with hypertension. Clinicians need to consider cardiovascular risk when prescribing GCs, and ensure blood pressure is regularly monitored and treated where necessary.

Association Between Chronic Inflammatory Diseases and Stroke-Associated Pneumonia - An Epidemiological Study

BACKGROUND

Pneumonia, the most common post-acute ischemic stroke (AIS) infection, accounts for up to 30% of deaths after a stroke. Multiple chronic inflammatory diseases, such as rheumatoid arthritis, psoriasis, and inflammatory bowel disease, are associated with increased risk of stroke and stroke morbidity. This study assessed the relationship between chronic inflammatory diseases and stroke-associated pneumonia (SAP).

METHODS

Using data from the 2015-2017 National Inpatient Sample, we classified hospital discharges with a diagnosis of AIS as having ulcerative colitis, Crohn's disease, rheumatoid arthritis, psoriasis, systemic lupus erythematosus, other chronic inflammatory diseases, multiple chronic inflammatory diseases, or none. With multivariable logistic regression, we assessed for associations between chronic inflammatory disease and in-hospital SAP or death.

RESULTS

Among AIS discharges, there was a decreased risk of SAP among those with psoriasis or other chronic inflammatory diseases (adjusted odds ratio (aOR) 0.70, 95%CI 0.63-0.99; aOR 0.64, 95%CI, 0.46-0.89, respectively), compared to those without psoriasis and without other chronic inflammatory disease, respectively. Rheumatoid arthritis, psoriasis, and other chronic inflammatory diseases were associated with reduced in-hospital mortality (aOR 0.89, 95%CI 0.78-1.00; aOR 0.77, 95%CI 0.59-1.00; aOR 0.69, 95%CI 0.50-0.94, respectively).

CONCLUSIONS

The risk of SAP and in-hospital mortality varies by chronic inflammatory disease - psoriasis and other chronic inflammatory diseases are associate with reduced rates of SAP, whereas rheumatoid arthritis, psoriasis and other chronic inflammatory disease were associated with reduced in-hospital mortality. Further investigations are needed to determine a relationship between the potential role of immunomodulation and the reduction in SAP and mortality in chronic inflammatory diseases.

[Safety aspects of the treatment with glucocorticoids for rheumatoid arthritis]

Glukokortikoide (GC) werden für die initiale Therapie der RA nach wie vor empfohlen – zeitlich befristet und in geringstmöglicher Dosierung. Ihre komplexe Wirkweise geht mit Nebenwirkungen einher, die v. a. in der Dauertherapie oberhalb von 5 mg Prednisolon pro Tag eine Rolle spielen. In diesem Dosisbereich begünstigen sie Osteoporose, Diabetes/Hyperglykämie, kardiovaskuläre Ereignisse und Infektionen und tragen damit zu einer vermehrten Frühsterblichkeit bei. Dabei sind die Risiken der GC-Therapie von patientenbezogenen Faktoren abhängig wie Alter, Komorbidität und Begleitmedikation. Ein negativer Einfluss sehr niedriger Steroiddosen auf das Gesamtüberleben ist möglicherweise bei hoher kumulativer Dosis nachweisbar, die Datenlage ist hier jedoch widersprüchlich. Das Monitoring einer GC-vermittelten Toxizität mithilfe eines validierten Index sollte in Zukunft dazu beitragen, die Vorteile einer steroidsparenden Behandlungsstrategie besser zu beschreiben. Selektiver wirkende Substanzen könnten in Zukunft eine Abkopplung der erwünschten Wirkungen von den Nebenwirkungen ermöglichen.

Psoriatic arthritis and the association with cardiometabolic disease: a narrative review

Psoriatic arthritis (PsA) is associated with a higher burden of cardiometabolic disorders, such as hypertension, dyslipidemia, diabetes, obesity, and cardiovascular disease (CVD), compared with the general population. These comorbidities are associated with the severity of disease, and adversely affect treatment outcomes in PsA. Comorbidities lead to increased physician visits and medications for patients and make the selection and maintenance of therapies challenging for physicians. Moreover, CVD is a leading cause of mortality in PsA. Therefore, optimal management of PsA should include not only treating the skin and joint disease, but also identifying comorbidities early, and managing them to improve long-term outcomes. Further studies are needed to understand the complex mechanisms, interactions, and trajectories of cardiometabolic comorbidities in psoriatic disease.

Managing Cardiovascular Risk in Patients with Rheumatic Disease

Individuals with rheumatoid arthritis, systemic lupus erythematosus, or gout have increased risk of cardiovascular disease (CVD) compared with the general population. This risk relates to a combination of traditional cardiovascular risk factors and disease-specific factors. Screening for CVD is important because CVD contributes to significant morbidity and mortality. Management includes tight control of disease activity to reduce inflammation, but with care to minimize use of nonsteroidal anti-inflammatory drugs and prolonged courses of high-dose corticosteroids. Traditional cardiovascular risk factors should be managed with a combination of lifestyle interventions and pharmacotherapy. The decision to start antihypertensive and lipid-lowering therapy should be based on individual CVD risk.

Patients with rheumatoid arthritis have impaired long-term outcomes after myocardial infarction - a nationwide case-control registry study

Objective

To investigate the long-term outcomes of patients with RA after myocardial infarction (MI).

Methods

All-comer, real-life MI patients with RA (n = 1614, mean age 74 years) were retrospectively compared with propensity score (1:5) matched MI patients without RA (n = 8070) in a multicentre, nationwide, cohort register study in Finland. The impact of RA duration and the usage of corticosteroids and antirheumatic drugs on RA patients’ outcomes were also studied. The median follow-up was 7.3 years.

Results

RA was associated with an increased 14-year mortality risk after MI compared with patients without RA [80.4% vs 72.3%; hazard ratio (HR) 1.25; CI: 1.16, 1.35; P <0.0001]. Patients with RA were at higher risk of new MI (HR 1.22; CI: 1.09, 1.36; P =0.0001) and revascularization (HR 1.28; CI: 1.10, 1.49; P =0.002) after discharge from index MI. Cumulative stroke rate after MI did not differ between RA and non-RA patients (P =0.322). RA duration and corticosteroid usage before MI, but not use of methotrexate or biologic antirheumatic drugs, were independently associated with higher mortality (P <0.001) and new MI (P =0.009). A higher dosage of corticosteroids prior to MI was independently associated with higher long-term mortality (P =0.002) and methotrexate usage with lower stroke rate (P =0.034). Serological status of RA was not associated with outcomes.

Conclusion

RA is independently associated with poorer prognosis after MI. RA duration and corticosteroid usage and dosage were independent predictors of mortality after MI in RA. Special attention is needed for improvement of outcomes after MI in this vulnerable population.

The relationship between rheumatoid arthritis and diabetes mellitus: a systematic review and meta-analysis

Supplemental Digital Content is available in the text.

Objective

This systematic review/meta-analysis was conducted to investigate the relationship between rheumatoid arthritis and the incidence of diabetes mellitus.

Methods

A comprehensive search was conducted up to 10 March 2020 in Medline (via Ovid), Embase (via Ovid) and Web of Science core collection to identify cohort studies comparing the risk of diabetes mellitus incidence in people with rheumatoid arthritis with the general population. The I2 statistic was used to test heterogeneity. Pooled relative risks were calculated using random-effects models. Publication bias was assessed using Egger’s test and Begg’s test.

Results

The initial search provided 3669 articles. Of those, five journal articles/two conference abstracts comprising 1 629 854 participants were included in this study. The funnel plot showed potential publication bias, proven by Egger’s test (−3.15, P < 0.01), but not Begg’s test (−0.05, P = 1.00). Heterogeneity was observed in I2 test (I2 = 96%, P < 0.01). We found that rheumatoid arthritis was associated with a higher risk of diabetes mellitus incidence (pooled relative risk, 1.23; 95% confidence interval, 1.07–1.40). Exploration of potential sources of heterogeneity found significant heterogeneity in different countries/regions (P = 0.002), but heterogeneity was NS in different study designs (P = 0.30). Sensitivity analyses confirmed that the association between rheumatoid arthritis and diabetes mellitus incidence was robust.

Conclusion

Rheumatoid arthritis is associated with an increased risk of diabetes mellitus incidence. This finding supports the notion that inflammatory pathways are involved in the pathogenesis of diabetes. More intensive interventions targeting diabetes risk factors should be considered in people with rheumatoid arthritis.

Risk for infections with glucocorticoids and DMARDs in patients with rheumatoid arthritis

Immunomodulatory therapy for rheumatoid arthritis (RA) carries risk for infectious complications. Understanding the risks of different therapeutic options is essential for making treatment decisions and appropriately monitoring patients. This review examines data on the risks for serious infections and other key infections of interest for the major classes of agents in use for RA: glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), biologics and Janus kinase (JAK) inhibitors. Conventional synthetic DMARDs have an excellent safety profile with recent data available supporting the relative safety of methotrexate. Tumour necrosis factor (TNF) inhibitors are associated with an increase in the risk of serious infections. Risk with other biological agents and with JAK inhibitors varies somewhat but overall appears similar to that of TNF inhibitors, with JAK inhibitors also associated with a greater risk of herpes zoster. Glucocorticoids have a dose-dependent effect on serious infection risk-at higher doses risk of infection with glucocorticoids is substantially greater than with other immunomodulatory therapies, and even low-dose therapy carries a risk of infection that appears to be similar to that of biological therapies.

Intervention Thresholds for Treatment in Patients with Glucocorticoid-Induced Osteoporosis: Systematic Review of Guidelines

Background

In this study, we aimed to evaluate and compare the treatment indication for patients with glucocorticoid-induced osteoporosis (GIOP) in various clinical practice guidelines.

Methods

We searched for potentially relevant studies conducted from January 2000 to March 2020 using online databases, including PubMed, Ovid-EMBASE, Guidelines International Network, National Institute for Health and Clinical Excellence, KoreaMed, KMbase, and KoMGI. We reviewed and analyzed the guidelines that included recommendations on GIOP and fulfilled the inclusion criteria.

Results

A total of 94 articles were selected based on review of the title and abstract; 14 guidelines were assessed upon reviewing the full text. The bone mineral density score for therapeutic intervention of GIOP in postmenopausal women was presented in 7 guidelines, among which 3 guidelines set a T-score of −2.5 or lower and the other 4 guidelines proposed a less stringent cut-off point of −1.5 or lower. Among the 10 guidelines published since 2012 after the emergence of the fracture risk assessment tool (FRAX), 6 guidelines included FRAX in their criteria for defining intervention thresholds. However, they were further divided into fixed-probability (n=3) and age-dependent (n=3) thresholds based on the country.

Conclusions

Recently developed guidelines use FRAX as the criterion for establishing the treatment of patients with GIOP. However, these intervention thresholds need to be adapted for each country.

Prognostic factors for the short-term mortality of patients with rheumatoid arthritis admitted to intensive care units

Background

Patients with rheumatoid arthritis (RA) have high mortality risk and are frequently treated in intensive care units (ICUs).

Methods

This was a retrospective observational study. This study included 67 patients (20 males, 47 females) with RA who were admitted at the ICU of our institution for ≥48 h between January 2008 and December 2017. We analyzed the 30-day mortality of these patients and the investigated prognostic factors in RA patients admitted to our ICU.

Results

Upon admission, the median age was 70 (range, 33–96) years, and RA duration was 10 (range, 0–61) years. The 5-year survival after ICU admission was 47%, and 30-day, 90-day, and 1-year mortality rates were 22, 27, and 37%, respectively. The major reasons for ICU admission were cardiovascular complications (24%) and infection (40%) and the most common ICU treatments were mechanical ventilation (69%), renal replacement (25%), and vasopressor (78%). In the 30-day mortality group, infection led to a fatal outcome in most cases (67%), and nonsurvival was associated with a significantly higher glucocorticoid dose, updated Charlson’s comorbidity index (CCI), and acute physiology and chronic health evaluation (APACHE) II score. Laboratory data obtained at ICU admission showed that lower platelet number and total protein and higher creatinine and prothrombin time international normalized ratio (PT-INR) indicated significantly poorer prognosis. The multivariate Cox proportional hazard model revealed that nonuse of csDMARDs, high updated CCI, increased APACHE II score, and prolonged PT-INR were associated with a higher risk of mortality after ICU admission.

Conclusion

Our study demonstrated that the nonuse of csDMARDs, high updated CCI, elevated APACHE II score, and coagulation abnormalities predicted poorer prognosis in RA patients admitted to the ICU.

Risk for Serious Infection With Low-Dose Glucocorticoids in Patients With Rheumatoid Arthritis : A Cohort Study

BACKGROUND

Low-dose glucocorticoids are frequently used for the management of rheumatoid arthritis (RA) and other chronic conditions, but the safety of long-term use remains uncertain.

OBJECTIVE

To quantify the risk for hospitalized infection with long-term use of low-dose glucocorticoids in patients with RA receiving stable disease-modifying antirheumatic drug (DMARD) therapy.

DESIGN

Retrospective cohort study.

SETTING

Medicare claims data and Optum's deidentified Clinformatics Data Mart database from 2006 to 2015.

PATIENTS

Adults with RA receiving a stable DMARD regimen for more than 6 months.

MEASUREMENTS

Associations between glucocorticoid dose (none, ≤5 mg/d, >5 to 10 mg/d, and >10 mg/d) and hospitalized infection were evaluated using inverse probability-weighted analyses, with 1-year cumulative incidence predicted from weighted models.

RESULTS

247 297 observations were identified among 172 041 patients in Medicare and 58 279 observations among 44 118 patients in Optum. After 6 months of stable DMARD use, 47.1% of Medicare patients and 39.5% of Optum patients were receiving glucocorticoids. The 1-year cumulative incidence of hospitalized infection in Medicare patients not receiving glucocorticoids was 8.6% versus 11.0% (95% CI, 10.6% to 11.5%) for glucocorticoid dose of 5 mg or less per day, 14.4% (CI, 13.8% to 15.1%) for greater than 5 to 10 mg/d, and 17.7% (CI, 16.5% to 19.1%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids). The 1-year cumulative incidence of hospitalized infection in Optum patients not receiving glucocorticoids was 4.0% versus 5.2% (CI, 4.7% to 5.8%) for glucocorticoid dose of 5 mg or less per day, 8.1% (CI, 7.0% to 9.3%) for greater than 5 to 10 mg/d, and 10.6% (CI, 8.5% to 13.2%) for greater than 10 mg/d (all P < 0.001 vs. no glucocorticoids).

LIMITATION

Potential for residual confounding and misclassification of glucocorticoid dose.

CONCLUSION

In patients with RA receiving stable DMARD therapy, glucocorticoids were associated with a dose-dependent increase in the risk for serious infection, with small but significant risks even at doses of 5 mg or less per day. Clinicians should balance the benefits of low-dose glucocorticoids with this potential risk.

PRIMARY FUNDING SOURCE

National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Treatment-related damage in elderly-onset ANCA-associated vasculitis: safety outcome analysis of two nationwide prospective cohort studies

BACKGROUND

It is not elucidated that there is treatment-related damage in elderly patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

METHODS

Elderly (≥ 75 years of age) patients were enrolled from two nationwide prospective inception cohort studies. The primary outcome was 12-month treatment-related Vasculitis Damage Index (VDI) score. Secondary outcomes included serious infections within 6 months, total VDI score, remission, and relapse. Patient characteristics and outcomes were compared across three different initial glucocorticoid (GC) dose groups: high-dose, prednisolone (PSL) ≥ 0.8 mg/kg/day; medium-dose, 0.6 ≤ PSL < 0.8 mg/kg/day; and low-dose, PSL < 0.6 mg/kg/day.

RESULTS

Of the 179 eligible patients, the mean age was 80.0 years; 111 (62%) were female. The mean Birmingham Vasculitis Activity Score was 16.1. Myeloperoxidase-ANCA findings were positive in 168 (94%) patients, while proteinase 3-ANCA findings were positive in 11 (6%). The low-dose group was older and had higher serum creatinine levels than the other groups. There were no statistically significant intergroup differences in remission or relapse, whereas serious infection developed more frequently in the high-dose (29 patients [43%]) than the low-dose (13 patients [22%]) or medium-dose (10 patients [19%]) groups (p = 0.0007). Frequent VDI items at 12 months included hypertension (19%), diabetes (13%), atrophy and weakness (13%), osteoporosis (8%), and cataracts (8%). Logistic regression analysis revealed that GC dose at 12 months (odds ratio, 1.14; 95% confidence interval, 1.00-1.35) was a predictor for diabetes.

CONCLUSION

A reduced initial GC dose with rapid reduction might be required to ensure the safe treatment of elderly AAV patients.

Risk of hospitalization from drug-drug interactions in the Elderly: real-world evidence in a large administrative database

The aim of this study was to assess the risk of hospitalization associated with the concomitant prescription of 10 highly prevalent drug-drug interactions (DDIs) among all individuals aged ≥65 residing in Bologna's area, Italy. We used incidence density sampling, and the effect of current (last month) and past (≥30 days before) exposure to DDI was investigated through conditional multivariable logistic regression analysis. Two DDIs were associated with increased hospitalization due to DDI related conditions: ACE-inhibitors/ diuretics plus glucocorticoids (current DDI: OR 2.36, 95% CI 1.94-2.87; past DDI: OR 1.36, 95% CI 1.12-1.65) and antidiabetic therapy plus current use of fluoroquinolones (OR 4.43, 95% CI 1.61-11.2). Non-Steroidal Anti-inflammatory Drugs (NSAIDs) increased the risk of re-bleeding in patients taking Selective Serotonin Reuptake Inhibitors (OR 5.56, 95% CI 1.24-24.9), while no significant effect was found in those without a history of bleeding episodes. Concomitant prescription of NSAIDs and ACE-inhibitors/diuretics in patients with a history of high-risk conditions was infrequent. Within the pattern of drug prescriptions in the older population of Bologna's area, we distinguished DDIs with actual clinical consequences from others that might be considered generally safe. Observed prescribing habits of clinicians reflect awareness of potential interactions in patients at risk.