Prednisone study..not so bad

[yogabonnie]

Hi. I just today read someone's post with a link to a study that said the Prednisone risks are NOT so bad as first thought. Can you repost? I have searched and searched. thanks

[Soraya_PMR]

I think this link is different, but think it’s the study by Matteson et al that you’re referring to:

medpagetoday.com/rheumatolo...

[PMRpro Ambassador]

practicalpainmanagement.com...

[yogabonnie in reply to PMRpro]

thanks sent it off to my doc

[Lara119 in reply to PMRpro]

Oh I suddenly feel a lot happier 😃

[nevagivup]

I was so happy after reading the link posted by PMTpro. It has ALWAYS been the principle of the two GP's I've been treated by that I have to get down as low as possible and off Pred as soon as possible. Hence many relapses/flares over the last 9 years. Now I am armed with good evidence that the principle is wrong and can argue my corner, by quoting the link. Thanks again, PMRpro.

[PMRpro Ambassador in reply to nevagivup]

I think that is why Eric Matteson has done the work - he is a member of the committee that drew up the Guidelines and I think he was concerned at the way so many doctors are terrified of any dose of pred. Once it is below the physiological level it is far less of a problem - that is about 8mg. So patients who are at 5mg or lower shouldn't be harassed at all..

I believe he has written an article for the NE of England PMRGCA newsletter about it.

[Lara119]

I too put myself under a lot of pressure to come off the steroids and have just had to start again because of pmr/gca relapse. I have always felt my body tolerated the steroids so well but still felt pressure. I feel a lot happier after reading this. Best wishes to you

[yogabonnie in reply to Lara119]

How had you tapered? and when did you have to go back up? Also. I know. Isn't PMRPro the best finding this link!

[Lara119 in reply to yogabonnie]

And yes she is!

[Lara119]

I tapered over 4 years very slowly but over the last 10 days or so my symptoms were really bad (I had finally come off completely at this time) . Blood test revealed it was active again. I think maybe I would be better on a maintenance dose rather than coming off completely but you have to try.

[yogabonnie in reply to Lara119]

Thanks. Sorry it was so discouraging..so especially good news this study!

[PMRpro Ambassador in reply to Lara119]

Yes, you have to try - but the last couple of mg should be desperately slowly and in very small steps, sticking at each dose for at least a month and preferably longer. And as soon as anything can be felt -stop, add a few mg and don't risk needing more. Part of it is the dripping tap of inflammation getting you to a stage you feel it - avoiding that is so important.

[Polywotsit PMRGCAuk team member]

Bear in mind that it is just one study - there needs to be more research! And the key finding here was about the risk of diabetes. There are many other risks of high cumulative doses of prednisolone that need to be taken into account. It's not how much you are on at any one time that is really the key point, but your cumulative dose over the years that you are taking pred.

[PMRpro Ambassador in reply to Polywotsit]

Have you read it? It isn't "a study". It is a retrospective analysis using a population-based inception cohort. With age-matched comparators. The abstract is here:

ncbi.nlm.nih.gov/pubmed/287...

The key finding wasn't of the risk of diabetes but cataracts:

"Those on lengthy treatment do experience a high rate of steroid-related complications, but except for cataracts, these comorbidities are no more common in PMR patients than in non-PMR patients."

Eric Matteson (a member of the committee that drew up the most recent guidelines) and co have looked at this BECAUSE they are concerned about the fear many doctors have of using pred in PMR and their tendency to rush people off pred before they are ready. This study agrees with the Italian study some years ago, saying that the "the median time to permanent discontinuation was 5.95 years (95% CI: 3.37-8.88)."

[Soraya_PMR in reply to Polywotsit]

"In the PMR and non-PMR comparator groups, the cumulative incidence rates at 5 years, respectively, were:

9.5% and 11.5% for diabetes

30.4% and 33.4% for hypertension

24.0% and 26.6% for hyperlipidemia

3.9% and 5.1% for hip or femoral neck fracture

3.9% and 2.4% for symptomatic vertebral fracture

2.4% and 2.5% for Colles fracture

9.5% and 11.5% for any fracture

The cumulative incidence of cataracts at 5 years after PMR incidence was 41.0% (95% CI 32.1%-48.7%) compared with 27.3% (95% CI 19.8%-34.2%) among the non-PMR comparators, corresponding to a hazard ratio of 1.72 (95% CI 1.23-2.41) adjusted for age, sex and calendar year. No patients developed avascular necrosis."

Right off the top of my head I wonder if the *symptomatic* vertebral fracture rate is slightly increased in those with PMR is due to the fact that those with PMR take prednisolone (or similar) as pain relief, whereas those with other arthritis and similar (I'm assuming these diseases due to age of sample) might be taking conventional analgesia, which could potentially be increased temporarily to control the pain, meaning that they don't present to doctor? PMR patient may present at doctor with new pain uncontrolled by steroids, and be investigated, leading to alternative diagnosis???

As regards the higher incidence of cataracts, bear in mind that many with PMR (MOST hopefully) will have been made aware of the potential for GCA, raised eye pressures, and may experience dry eye due to steroid side effects. Any/all of these issues will take a person to an optician/specialist, and therefore diagnosis of early cataract may be made, which otherwise would have been overlooked. Impossible to do, but would have been interesting to see what the figures were if each of the non-PMR patients were followed up with an eye exam. But as far as complications/side effects go, cataracts are dealt with on a daily basis within the NHS, and has an excellent outcome from surgery.

3.9% and 5.1% for hip or femoral neck fracture

: is a very interesting figure. Risk of osteoporosis/fractures is increased with immobility and poor mobility, particularly in the elderly (median age in this piece of work was 74.9) Untreated/under-treated PMR will lead to immobility and poor mobility, so in that regard, I'd stick my neck out to say that steroid treatment would actually prevent fractures by promoting normal mobility. JUST MY OPINION!

Yes this is only one 'study'. But a refreshing change from the usual regurgitation from medics as to the side effects, as this is not theory, it has followed real people with real lives and counted what actually happens.

The other 'real life' indication is the length of steroid use in PMR. Longer than doctors and (English) medical books would have us believe. 50% discontinued by 5 years, which means 50% continued past the 5 years, and each of those patients must have had a Doctor/Rheumatologist behind them accepting the continued use of steroids. It doesn't add up really does it?

[PMRpro Ambassador in reply to Soraya_PMR]

I agree with all your points - been saying it for some time! Immobility due to PMR is a major risk factor for pretty much everything - except cataracts!

The standard German rheumatology book says 5 years. A study on using methotrexate done in Italy found that whether they had been on mtx or not, a third of patients were still requiring pred, albeit at a pretty low dose, at 6 years. Funny how they push the "mtx does reduce pred dose requirement" but not the evidence that PMR doesn't go away in the mythical 2 years!