Respiratory Infectious Disease

Corticosteroid Dose Predicts Mortality in Rheumatic Diseases Plus Pneumonia

Avatar photoMaria Arini Lopez, PT, DPT, CSCS, CMTPT
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It is unclear whether disease control prevents RA-related bone loss, but data suggest it does in patients with early RA and high disease activity.1 Two systemic analyses of RA studies concluded that biologic DMARDs reduce generalized and localized bone loss.2,19 However, few studies were phase 3 trials, and most measured markers of bone turnover.2,19 High-quality trials that measure BMD change or fracture risk are needed. Bisphosphonates, denosumab, and parathyroid hormone are agents approved for osteoporosis and glucocorticoid-induced osteoporosis. Bisphosphonates and denosumab appear to have similar efficacy at preserving BMD.1 In some RA studies, denosumab also prevented and repaired erosions.2 The ACR guidelines for glucocorticoid-induced osteoporosis categorize patients as having low, moderate, or high fracture risk.18 They recommend calcium (1000 to 1200 mg/d) and vitamin D (600 to 800 IU/d) supplements for all patients, plus an osteoporosis agent (preferably an oral bisphosphonate) for patients with moderate to high fracture risk.

It is unclear whether disease control prevents RA-related bone loss, but data suggest it does in patients with early RA and high disease activity.1 Two systemic analyses of RA studies concluded that biologic DMARDs reduce generalized and localized bone loss.2,19 However, few studies were phase 3 trials, and most measured markers of bone turnover.2,19 High-quality trials that measure BMD change or fracture risk are needed. Bisphosphonates, denosumab, and parathyroid hormone are agents approved for osteoporosis and glucocorticoid-induced osteoporosis. Bisphosphonates and denosumab appear to have similar efficacy at preserving BMD.1 In some RA studies, denosumab also prevented and repaired erosions.2

The ACR guidelines for glucocorticoid-induced osteoporosis categorize patients as having low, moderate, or high fracture risk.18 They recommend calcium (1000 to 1200 mg/d) and vitamin D (600 to 800 IU/d) supplements for all patients, plus an osteoporosis agent (preferably an oral bisphosphonate) for patients with moderate to high fracture risk.

Researchers assessed the effect of adjunctive corticosteroid therapy on mortality outcomes in patients with rheumatic diseases complicated by Pneumocystis jirovicii pneumonia.

Daily adjunctive corticosteroid dose was found to be significantly predictive of mortality outcomes in patients with rheumatic diseases complicated by Pneumocystis jirovicii pneumonia, according to study findings published in the International Journal of Infectious Diseases.

Researchers conducted a retrospective study among patients with rheumatic diseases complicated by P jirovicii pneumonia at the National Taiwan University Hospital in Japan between November 2015 and April 2021. All patients received adjunctive corticosteroid therapy in addition to first-line treatment for pneumonia. First-line treatment was either trimethoprim-sulfamethoxazole or anidulafungin. Patients were categorized into 2 groups, including survivors and nonsurvivors, and multivariable logistic regression was used to determine significant factors associated with in-hospital, 30-day, and 90-day mortality.

There were 72 patients included in the final analysis, of whom the median age was 59.5 (IQR, 44.5-66.8) years, 55.6% were women, the median duration of rheumatic disease was 23.5 (range, 3.3-104.0) months, and the median pneumonia severity index (PSI) score was 101.5 (IQR, 77.0-132.0). Of note, the majority of patients (95.8%) were receiving corticosteroid therapy prior to baseline.

Of patients who survived (n=34) and those who died (n=38), the median adjunctive corticosteroid dose was 0.44 (IQR, 0.29-0.54) and 0.85 (IQR, 0.63-1.05) mg/kg/day (P <.001), respectively. The rate of all-cause mortality among patients who died was 36.1% at 30 days and 52.8% at 90 days.

The researchers found that a median adjunctive corticosteroid dose of 0.6 mg/kg/day was the optimal cutoff point for predicting in-hospital (sensitivity, 78.9%; specificity, 82.4%), 30-day (sensitivity, 80.8%; specificity, 67.4%), and 90-day (sensitivity, 76.3%; specificity, 79.4%) mortality.

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Multivariable logistic regression showed that a median adjunctive corticosteroid dose of at least 0.6 mg/kg daily (odds ratio [OR], 5.86; 95% CI, 1.36-25.33; P =.018) and a PSI score of more than 90 (OR, 11.23; 95% CI, 2.32-54.37; P =.003) were significantly associated with in-hospital mortality. A median adjunctive corticosteroid dose of at least 0.6 mg/kg daily also was significantly associated with 30-day (OR, 4.57; 95% CI, 1.27 to 16.42; P =.020) and 90-day (OR, 4.68; 95% CI, 1.22-17.94; P =.024) mortality, with similar results noted for a PSI score of more than 90 for both 30-day (OR, 5.72; 95% CI, 1.39-23.61; P =.016) and 90-day (OR, 10.86; 95% CI, 2.47-47.71; P =.002) mortality.

A sensitivity analysis was performed after the exclusion of patients who received first-line treatment with anidulafungin. Results showed that an increased risk of in-hospital mortality was significantly associated with a median adjunctive corticosteroid dose of at least 0.6 mg/kg daily (OR, 7.5; 95% CI, 1.48-37.16; P =.015), a PSI score of more than 90 (OR, 10.38; 95% CI, 1.85-58.23; P =.008), and a current bloodstream infection (OR, 9.61; 95% CI, 1.05-88.38; P =.045).

This study was limited by its retrospective design, single-center setting, and the inclusion of patients with both probable and laboratory-confirmed Pneumocystis pneumonia.

These findings “provide further evidence for the association between adjunctive corticosteroid dosage and prognosis in [P jirovicii pneumonia],” the researchers concluded.

Reference

Huang YM, Lu CH, Cheng CF, et al. Clinical features and prognostic predictors in patients with rheumatic diseases complicated by Pneumocystis pneumonia. Int J Infect Dis. Published online July 30, 2022. doi:10.1016/j.ijid.2022.07.070

This article originally appeared on Infectious Disease Advisor

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