Using parenteral instead of oral for glucocorticoids in early RA was associated with substantially less ongoing oral steroid use without an apparent penalty in disease control.
Giving glucocorticoids by injection rather than orally may help patients with early rheumatoid arthritis get off steroids sooner, according to new real-world data.
Researchers found patients treated with parenteral glucocorticoids in the first three months after diagnosis had 60% lower adjusted odds of still using glucocorticoids at one year compared with patients initially treated with oral steroids.
The difference did not appear to come at the cost of poorer rheumatoid arthritis control or greater use of advanced therapies, they said.
“Using parenteral GCs instead of oral might decrease the long-term use of GCs among patients with ERA,” they wrote.
“This change could reduce steroid-related side effects, with similar disease control and outcomes.”
The findings, published in the Annals of the Rheumatic Diseases, came from an analysis of 2222 adults with newly diagnosed early rheumatoid arthritis enrolled in the Canadian Early Arthritis Cohort (CATCH) between 2007 and 2023.
Patients had symptoms for less than a year and were followed for 12 months and the median age was 55 years.
Three-quarters of patients received no glucocorticoids during the first three months, while 19% received oral glucocorticoids, 5% received parenteral treatment – intra-articular and/or intramuscular – and 1% received both.
Those prescribed glucocorticoids generally started with more active disease. Patients receiving oral steroids had a mean baseline Clinical Disease Activity Index (CDAI) of 31.6, compared with 30.2 among those receiving parenteral glucocorticoids and 24.1 among patients receiving no glucocorticoids.
But the trajectories diverged when researchers looked at continued steroid use.
At six months, 60% of the oral glucocorticoid group remained on glucocorticoids, compared with 26% of the parenteral group.
By 12 months, 47% of patients initially treated with oral glucocorticoids were still using them, compared with 26% of those initially given parenteral treatment.
Among patients who had received neither during the first three months, 8% were using glucocorticoids at one year.
After adjustment for factors including age, sex, education, comorbidity, symptom duration, baseline disease activity, methotrexate treatment and site size, patients initially receiving parenteral rather than oral glucocorticoids had 60% lower odds of glucocorticoid use at 12 months (OR 0.4, 95% CI 0.3-0.7).
There was no corresponding difference in escalation to advanced treatment. At one year, 14% of both the oral and parenteral groups were receiving advanced therapies, and the adjusted odds were identical when the two routes were directly compared (OR 1.0, 95% CI 0.5-1.9).
Disease activity also improved substantially across all groups. By 12 months, mean CDAI scores were 8.5 in the oral group and 8.1 in the parenteral group, while mean DAS-28 scores were 2.7 in both groups.
Neither measure differed significantly across the treatment groups at that point.
Related
The researchers said the findings were potentially important because guidelines recommended glucocorticoids be tapered and discontinued as rapidly as clinically feasible, ideally within three to six months.
Yet prolonged steroid exposure remained common in routine rheumatoid arthritis care and carried risks including osteoporosis, infection, diabetes and other adverse effects, they wrote.
The researchers suggested injections could make prolonged exposure less likely because they allowed more controlled dosing and remove some of the opportunity for unscheduled dose escalation or prescription renewal.
“Mounting clinical trials and real-world evidence suggest that parenteral GC offers advantages over oral GC in ERA treatment,” they wrote.
“Parenteral administration enables controlled dosing, reduces opportunities for unscheduled dose escalation, and may help limit long-term GC exposure – thereby reducing cumulative toxicity.
“This approach aligns with contemporary guidelines advocating for rapid tapering and discontinuation of GC within a treat-to-target framework and may help clinicians achieve GC-free remission or low disease activity more effectively.
“However, the observational design means the study cannot establish that the route of administration itself caused the difference.”
The researchers also could not distinguish intra-articular from intramuscular glucocorticoids in the CATCH database, despite the two approaches being used in different clinical circumstances.
Steroid dose and type were inconsistently captured, meaning cumulative exposure could not be reliably calculated.
Nevertheless, the authors said the findings add to evidence that parenteral glucocorticoids could provide a practical bridging strategy while disease-modifying therapy takes effect.
“In conclusion, the use of parenteral GC (intramuscular or intra-articular) halved the chances of continuing with GC at 12 months compared with oral GC, in a cohort of Canadian new patients with ERA followed over the first year,” they wrote.
“Although patients receiving early GCs had higher baseline disease activity, scores converged across all groups by 12months.
“Parenteral GC administration appears to reduce both the cumulative dose and duration of GC exposure, supporting greater adherence to contemporary guidelines encouraging rapid GC tapering.
“These findings highlight the potential role of parenteral GC as an effective and practical bridging strategy in early RA management.”
