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To the Editor,
I read the article by Hua et al.1 that was published in this journal with great interest. The authors provided an excellent review of the literature regarding the clinical efficacy and toxicity of glucocorticoids (GCs) in rheumatoid arthritis (RA). The review included comprehensive discussion about the efficacy of GCs as a bridging therapy in addition to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) based on the rapid onset of action of these drugs.1 The authors advocate that because even low-doses of GCs might have adverse effects, administration of these drugs should be restricted to the lowest dose for the shortest time.1 The first part about the effectiveness of GCs was well documented and convincing; however, the second part about the safety of these drugs seemed a little less convincing. This might be attributed to the fact that a small number of studies on the safety of GCs have been published. In particular, little evidence regarding bone-related adverse effects has been presented. We have obtained very preliminary data in our hospital about the effects of GCs on bone health, including fractures and osteoporosis, and would like to contribute these as a comment.
We retrospectively reviewed the medical records of 883 patients with RA who visited our hospital in 2018. Of these, 364 patients (41.2%, Figure 1A) were prescribed GCs. At the last visits in 2018, appro...
We retrospectively reviewed the medical records of 883 patients with RA who visited our hospital in 2018. Of these, 364 patients (41.2%, Figure 1A) were prescribed GCs. At the last visits in 2018, approximately 80% of the patients who were receiving GCs used 5 mg/day or less of GCs; the mean dosage was 4.1 mg/day (Figure 1B). Vertebral fractures were more frequently observed in patients who were receiving GCs than in those not receiving them (p = 0.028, Figure 1C). The incidence of non-vertebral fractures was the same regardless of GC use (Figure 1D). Osteoporosis, defined as <80% of the young-adult mean bone mineral density of the lumber spine or left femoral neck, was diagnosed in 195 patients (22.1%). The incidence of osteoporosis was twice as high among patients who were receiving GCs compared with those who were not receiving them (Figure 1E). The effect of GCs on osteoporosis was observed in both male and female patients (Figure 1F).
Figure is available upon request.
Patients with RA are at a high risk of fracture, and the use of GCs for more than 3 months is associated with an increased risk of vertebral fracture regardless of the dosage.2,3 Our data were very preliminary, and thus, it had several limitations. For example, we did not consider differences in patient backgrounds. However, this simplified retrospective study supports, at least in part, the concept that GCs should be used at minimal dosage and for the shortest duration possible.1
The study protocol was approved by the Ethics Committee of the Osaki Citizen Hospital (No. 20190822-25) and performed in accordance with the Declaration of Helsinki.