Medical record linkage study discovers that patients receiving low dose steroid are at an increased risk of cardiovascular disease

Medication used to treat a range of inflammatory diseases may be less safe than previously thought.

A large primary care linkage study has revealed that medication used to treat a range of inflammatory diseases may be less safe than previously thought. 

Glucocorticoids are steroids that are widely prescribed to treat a range of immune-mediated inflammatory diseases. While high doses of steroids are known to increase the risk of cardiovascular disease, the impact of lower doses is unknown.  

A study published in PLOS Medicine by Dr Mar Pujades-Rodriguez and colleagues Professor Ann Morgan, Dr Richard Cubbon, and Dr Jianhua Wu at Leeds University, suggests that even low doses of glucocorticoid may increase the risk of cardiovascular diseases.

The findings of our study highlight the importance of treating patients with the minimal effective dose of steroids for the shortest duration of time, while appropriately, promptly and regularly monitoring cardiovascular risk.

To quantify glucocorticoid dose-dependent cardiovascular risk, researchers analysed medical records of 87,794 patients diagnosed with 6 different immune-mediate inflammatory diseases receiving care from 389 United Kingdom primary care clinics in 1998-2017. The researchers found that during periods in which patients used less than 5 milligrams prednisolone per day, the absolute risk of cardiovascular disease nearly doubled compared to patients not using glucocorticoids (Hazard Ratio = 1.74; 95% confidence interval 1.64–1.84).

Increased dose-dependent risk ratios were found across all CVDs measured, including atrial fibrillation, heart failure, acute myocardial infarction, peripheral arterial disease, cerebrovascular disease, and abdominal aortic aneurysm.

Implementing and evaluating targeted intensive cardiovascular risk factor modification interventions, beyond diagnosis of inflammatory arthropathies and systemic lupus erythematosus, even when prescribing low glucocorticoid doses is essential.

Previously, it was believed that taking glucocorticoids equivalent to 5 mg of prednisolone per day over the long-term was safe, but the study suggests that even patients taking low doses have double the risk of developing cardiovascular disease.

These findings suggest patients needing long-term steroid treatment should be prescribed the lowest effective dose and have a personalized cardiovascular risk prevention plan that accounts for past and current steroid use. Prof Ann Morgan said that: “This study highlights the importance of finding new treatments to replace steroids, particularly in polymyalgia rheumatica and giant cell arteritis where there are few steroid-sparing treatments currently available”.

Although the study was limited by the lack of available hospital data on prescription and drug adherence and this may have reduced the size of dose-response estimates, the authors believe that the large sample size from an unselected population contributes to greater generalizability of the results.

The author’s findings highlight the importance of implementing and evaluating targeted intensive cardiovascular risk factor modification interventions; promptly and regularly monitor patient cardiovascular risk, beyond diagnosis of inflammatory arthropathies and systemic lupus erythematosus, even when prescribing low prednisolone-equivalent doses.

The authors, would like to stress that glucocorticoids (steroids) should not be stopped suddenly on reading this article, since this may lead to life-threatening complications or flares in the underlying inflammatory disease. Higher doses of steroids may be needed when people taking long-term steroids are unwell and more information can be found here.

Further information:

The Research Article is freely available.

For media enquiries contact University of Leeds press officer Simon Moore on S.I.Moore@leeds.ac.uk.