POS0137 INITIATION OF GLUCOCORTICOIDS BEFORE ENTERING RHEUMATOLOGY CARE ASSOCIATES WITH LONG-TERM GLUCOCORTICOID USE IN ELDERLY PATIENTS WITH EARLY RHEUMATOID ARTHRITIS: A JOINT ANALYSIS OF MEDICARE AND THE RHEUMATOLOGY INFORMATICS SYSTEM FOR EFFECTIVENESS (RISE) DATA
Authors: A. Palmowski, E. Roberts, J. Li, E. Kersey, R. Stovall, F. Buttgereit, J. Yazdany, G. Schmajuk
Journal: Annals of the Rheumatic Diseases (2024)

<h3>Background:</h3> Guidelines recommend avoiding glucocorticoids (GCs) (ACR[1]) or only using them for brief periods (EULAR[2]) in rheumatoid arthritis (RA). Despite potential risks of adverse events with long-term GC use, especially in the elderly, global research documents persistent use.[3-5] One previously unexamined factor possibly increasing the risk of long-term use is initiation of GCs before entry to rheumatologic care. <h3>Objectives:</h3> To investigate U.S. real-world GC usage patterns in elderly early RA (eRA) patients and to assess the relationship between GC initiation, entrance into rheumatologic care, and subsequent, long-term GC use. <h3>Methods:</h3> Data from the Rheumatology Informatics System for Effectiveness (RISE) registry and Medicare (2016-2018) were linked. Using RISE allowed for collecting detailed clinical data while GC use across the continuum of care in relation to entrance to rheumatology care was captured with Medicare claims. Patients aged ≥65 years with ≥2 RA ICD codes in RISE were included; the date of the first ICD code was the index date and signaled entrance into rheumatology care. GC initiation (between 3 months before to 6 months after the index date) and continuous GC use up to 12 months after the index date were captured with Medicare claims. Continuous GC use was defined as claims without medication gap periods of &gt;6 months. Covariates were mostly captured in RISE for 6 months following the index date. Figure 1 shows the study design. Kaplan-Meier curves were constructed to show the duration of GC use in patients initiating GCs before versus after the index date, and Cox proportional hazards models assessed this comparison with adjustment for confounders. In the main model, age, sex, race/ethnicity, area deprivation index, Charlson comorbidity index, body mass index, seropositivity, and DMARD initiation (yes/no) were included. The second model additionally adjusted for disease activity (CDAI or RAPID3; if both were available, CDAI was preferred). Patients with and without COPD were compared as COPD can be a competing indication for GCs. Finally, average daily GC doses were estimated. <h3>Results:</h3> 1,733 patients (67% female; mean age 76 ± 6 years; 86% non-Hispanic white) were included. 41% initiated GCs, on average 16 ± 58 days before entering rheumatologic care. Initial GC prescriptions received before the RA diagnosis came mostly from primary care/internal medicine subspecialty clinicians (38%), followed by rheumatologists (37%). The mean duration of GC use was 157 days (95%CI 143 to 170); 21% were still using GCs after 12 months. GC initiation before rheumatologic care was associated with longer GC use (Figure 2), even after adjustment for confounders (main model [n=629]: hazard ratio [HR] 0.61; 95%CI 0.51 to 0.74; model including disease activity [n=262]: HR 0.70; 95%CI 0.51 to 0.95). COPD did not affect the duration of GC use (data not shown). For patients using GCs for ≥3 months, average daily GC doses were &lt;5mg/d prednisone equivalent. <h3>Conclusion:</h3> GCs are regularly used in eRA and most often initiated before patients enter rheumatology care. Long-term, low-dose GC use is common and associated with initiation before rheumatology care. Initiatives to reduce GC exposure in RA will require close collaboration between rheumatologists and referring physicians. <h3>REFERENCES:</h3> [1] Fraenkel L <i>Arthritis care &amp; research</i> 2021. [2] Smolen JS <i>Ann Rheum Dis</i> 2023. [3] Andersen KM <i>ACR Open Rheumatology</i> 2022. [4] Roubille C <i>Ann Rheum Dis</i> 2017. [5] Xie W <i>Ann Rheum Dis</i> 2021. <h3>Acknowledgements:</h3> <b>NIL.</b> <h3>Disclosure of Interests:</h3> Andriko Palmowski Novartis, Eric Roberts: None declared, Jing Li: None declared, Emma Kersey: None declared, Rachael Stovall: None declared, Frank Buttgereit Abbvie, Horizon Therapeutics, Pfizer, and Sparrow, Horizon Therapeutics, Pfizer and Abbvie, Jinoos Yazdany Pfizer and Astra Zeneca, Gilead, Astra Zeneca, BMS Foundation and Aurnia, Gabriela Schmajuk: None declared.