Written By: Amna Batool, Susan Mansourian, Elise McVeigh, Saurav Suman, Kristine Lohr; University of Kentucky Fellowship Program
Based on: Yao et al, Ann Intern Med. 2020;173:325-330. doi:10.7326/M20-0432
Topic Overview
This study examines the side effects of a short course of oral corticosteroid burst dosing (up to14 days). The researchers reviewed the entire nationwide population of Taiwan using health insurance research database between the ages of 20-64 years that included more than 15 million adults, with over 2 million who received at least one steroid burst in the final analysis. The median dose of steroid was prednisone 10mg/day and the median duration of use was 3 days. The most common indication of steroid use were skin diseases and respiratory illness. Rheumatological diseases were not listed among the conditions requiring steroid burst.
The researchers specifically looked at the risk of severe adverse effects such as: GI bleeding, sepsis and heart failure up to 90 days after steroid use. The incidence rate per 1000 person – year among steroid users were: 27.1 for GI bleeding; 1.5 for sepsis, and 1.3 for heart failure. They found elevated risk of GI Bleeding (Incidence rate ratio (IRR): 1.8), sepsis (IRR: 1.99) and heart failure (IRR: 2.37) in people who received short steroid burst compared to those who did not receive it. This risk was significantly increased within 1st 5-30 days after the steroid dose and then gradually decreased afterwards over 31 – 90 days but still was significant. Final analysis adjusted for other concomitant medication that could confound the results such as NSAID and PPIs.
Implications for Patients, Providers, & Researchers
Current implications: This study emphasizes the elevated risk for side effects of even short course use of steroids, which is an important consideration that Rheumatology providers need to keep in mind when prescribing for disease flares. Evidence regarding short bursts of steroids regarding potential risks of treatment is limited. Thus, this study provides new insight into short-term risk following burst dosing.
Future implications: The future implications of this study include making Rheumatology providers more cognizant of the short-term risks associated with steroid burst for disease flares. Additionally, this study did not focus on rheumatologic disease patients, but should encourage Rheumatology researchers to specifically evaluate use of burst steroids in rheumatologic patients. Next steps may also implicate future research to determine optimal steroid burst duration to limit side effects and improve patient safety.
Will HoSTS Win its First Round Match-up?
“Harms of Short-Term Steroid” (HoSTS) and “SEMIRA” are both strong teams, with a lot of potential. However, in a match-up, HoSTS has the upper hand, because it is tackling the burning question that not only rheumatologists, but physicians of all fields, face on a daily basis: “Does this patient need a steroid taper today?” Granted, the study was not focused on rheumatological conditions perse. However, it managed to highlight the significant risk of steroids at doses and durations shorter than an average rheumatologist would prescribe, in a large population healthier than rheumatologists see every day! This will make rheumatologists as well as the general medical community, think twice before reaching for the electronic prescription pad!
SEMIRA on the other hand, has the advantage of focusing on RA patients, and is tackling the popular question of “Does this RA patient need a steroid taper today?” The trial highlights that steroid tapers are possibly used more often than required, however results do not offer a clear guidance regarding a taper regimen. Both teams need follow-up studies to tailor their outcome. However, in a match amongst the two, seems like winning the first round is a slam dunk for team HoSTS!
Could HoSTS Win it All?
It’s improbable but not impossible for Team Harms of Short Term Steroids (HoSTS) to win the tournament, as it could be a jumping point for additional research for something miraculous like a steroid alternative with less side effects. Assuming team HoSTS can pull through to the final face-off, it should be wary of the Avacopan trial as it may implicate the beginning of steroid alternatives.
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