Background/Purpose: Corticosteroids (CS) are a double edged sword in rheumatoid arthritis (RA) treatment. Low doses may have disease modifying effects but long-term use risks detrimental side-effects. Treat-to-target strategies with intense use of disease-modifying anti-rheumatic drugs (DMARDs) and biologic response modifiers as steroid-sparing agents have impacted RA management in recent years, but it is unknown whether this has actually resulted in less CS use. The purpose of this study was to examine trends in CS use among patients diagnosed with RA in 1995-2007 compared to 1980-1994.

Methods: A population-based inception cohort of patients with RA who fulfilled 1987 ACR criteria for RA in 1980-2007 was assembled. All subjects were followed longitudinally through their complete medical records until death, migration or 12/31/2008. RA disease characteristics, DMARD use, and CS doses were ascertained by medical record review, including the use of oral, intravenous and intramuscular CS, their start date, stop date and number of weeks to taper. Cumulative incidence of CS initiation and discontinuation was computed with adjustment for competing risk of death.  The current prevalence of CS use was estimated as the fraction of subjects on CS from among those under observation during each month of RA duration.

Results: The study population comprised 349 (68% female) diagnosed in 1980-1994 and 464 (69% female) diagnosed in 1995-2007, with mean followup of 15.3 and 5.7 years, respectively. Mean age was 55 years and 66% were rheumatoid factor positive in both cohorts. Those in 1995-2007 had a higher BMI (28.6 vs 26.8, p<0.001) and lower mean ESR at diagnosis (23.0 vs 27.2 mm/hr, p<0.001) than in 1980-1994. More patients started DMARDs in the 1^st year of disease in 1995-2007 than in 1980-1994 (83% vs. 52%, p<0.001). A higher proportion of patients started CS in their 1^st year of disease in 1995-2007 (68% vs 36%, p<0.001), but the starting dose (mean 8.7 vs 10.3 mg, p=0.08) and cumulative dose in the 1st year of use (mean 1.8 g vs 2.1 g, p=0.48) were not different than in 1980-1994. Differences in CS initiation in 1995-2007 vs 1980-1994 persisted throughout followup (81% vs 50% at 5y, 89% vs 62% at 10y; p<0.001). Discontinuing CS for at least 90 days was also more common in the 1995-2007 cohort than in the 1980-1994 cohort (41% vs 31% at 1 year after CS start, 78% vs 51% at 5y, 94% vs 69% at 10y; p<0.001). Current prevalence of CS use according to RA duration is displayed in the figure.

Conclusion: A higher proportion of patients are starting CS early in their disease course now compared to previously. Although more patients are also discontinuing CS now compared to previously, the proportion of patients on CS at any given time point of disease duration is higher now than previously.