Background/Purpose: High dose glucocorticoids (GC) are part of the initial treatment of ANCA-associated (AAV) and large vessel vasculitides (LVV). Prompt subsequent tapering limits toxicity. Adherence to tapering recommendations has not been studied. Among patients referred to a tertiary vasculitis clinic for either AAV or LVV, we aimed to determine the frequency of adherence to GC tapering recommendations, barriers to appropriate GC tapering, and possible improvement strategies.

Methods: Consenting new patients assessed July 2017-March 2019 for AAV (including GPA, EGPA, MPA) and LVV (GCA, Takayasu arteritis) were included. Referral specialty, diagnosis, wait time, GC dose and duration were recorded. Patients taking >10 mg prednisone above their target dose based on tapering recommendations were classified as taking ‘excessive’ GC. Physicians who referred 2 patients in the last year (n=31) were invited to complete a survey to identify barriers to GC tapering and potential solutions.

Results: Of 231 patients referred for AAV/LVV during the study period, 128 (55%) were taking GC at their first visit. Mean prednisone start dose was 53.5 mg (SD 14) and 33/111 (30%) received pulse GC. At the first visit (mean wait time 63 days, SD 31), mean GC dose was 30 mg (SD 18). 35 (27%) patients were taking excessive GC (17 AAV, 18 LVV), 11 of whom had not started tapering entirely. There were no significant differences in referral specialty, diagnosis, or wait times among patients taking ‘excessive’ vs ‘appropriate’ doses. Initial GC ‘pulses’ had been given to 14/31 (45%) of the ‘excessive’ group patients vs 19/80 (24%) in the ‘appropriate’ group (NS). 73% of survey respondents (n=14, 93% rheumatologists) felt “very comfortable” tapering GC  in GCA, but only 43% and 21% in AAV or Takayasu arteritis, respectively. Challenges with tapering were managing the risk of disease flare (79%) and differentiating active disease from damage (64%). Most (93%) felt that providing GC tapering suggestions at the time of referral would improve timely tapering, and 64% felt reducing wait times would help.

Conclusion: Nearly one third of patients referred for LVV or AAV were taking excessive GC doses at their first visit. There may be a referral bias to our clinic, and excessive GC use may reflect more challenging cases. Providing a GC tapering “action plan” at the time of referral may help to promote timely GC tapering.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/timely-glucocorticoid-tapering-in-vasculitis-a-need-for-improved-knowledge-translation-to-limit-toxicity/