Glucocorticoids in Older and Poorer Patients

Washington, DC—Despite current guidelines that recommend the use of disease-modifying antirheumatic drugs (DMARDs) for treatment of active rheumatoid arthritis (RA), many people are still treated with glucocorticoids alone for long periods of time. These people tend to be older and poorer, with no access to care by a rheumatologist.

This was the conclusion of a study presented at the ACR meeting that was undertaken to examine the prevalence and predictors of using glucocorticoids alone for the treatment of RA. The authors wanted to understand the magnitude of the gap in quality of care among patients with RA based on studies that have shown a low rate of DMARD use in older and poorer patients.

Using 2009 data from a 5% random sample of Medicare fee-for-service beneficiaries enrolled in Part D, investigators from the University of California, San Francisco examined the prevalence and predictors of receiving sustained glucocorticoids among a cohort of 8062 patients. All patients in the sample were ≥65 years of age, had ≥2 face-to-face encounters for RA, were continuously enrolled in Part D, and had ≥1 DMARD dispensed or had received sustained glucocorticoid monotherapy. Sustained glucocorticoid monotherapy was defined as receiving an annual glucocorticoid (prednisone or steroid equivalent) supply of >180 days or an annual dose of >900 mg, and no DMARD dispensed during the year.

Overall, the mean age of the entire cohort was 76 years, 81% were female, 85% were white, 23% were of low income, 69% had ≥1 drug prescription from a rheumatologist, and 23% had ≥1 inpatient admission.

Of the 8062 patients, 830 (10%) received sustained glucocorticoids alone.

After adjusting for race/ethnicity, physician office visits, hospitalizations, prescriptions by a rheumatologist, county poverty, and professional shortage area, patients who received sustained glucocorticoids were older (18% among those >85 years of age vs 11% among those 74 to 79 years of age) and had lower income (12% vs 10% for those with higher income). Geographical differences did not vary greatly, with higher rates of glucocorticoid monotherapy in the Mid-Atlantic region compared with the Pacific region (13% vs 8%, respectively).

A key finding of the study, according to Jinoos Yazdany, MD, MPH, a co-investigator of the study, was the influence of seeing a rheumatologist on whether a patient received a DMARD or sustained glucocorticoids.

“Only 6% of patients who saw a rheumatologist were on a glucocorticoid alone versus 16% for patients who did not see a rheumatologist,” she said

According to Dr. Yazdany, this may be because most primary care physicians are not comfortable prescribing DMARDs. She stressed that the study shows that access to a rheumatologist predicted DMARD use. “Even seeing a rheumatologist once will lead to a prescription of a DMARD,” she said.

The study also showed that patients least likely to see a rheumatologist were low-income patients, with 31% of the patients in the study deemed low income. She said that these people were not offered DMARDs even though they would receive full coverage of the drugs under Medicaid.

Dr. Yazdany concluded that the study highlighted the need to track DMARD use in poor populations, as well as to address the equitable use of specialty resources.