Glucocorticoid use and its association with damage accrual in The Systemic Lupus International Collaborating Clinics Inception Cohort

Abstract

Aim: The first aim of this thesis was to explore the use of glucocorticoids (GCs) in the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort and examine factors associated with variation in this use. The second aim was to group items of damage according to their likely association with GCs and explore patterns of damage accrual within these groupings in the SLICC cohort. Methods: The SLICC inception cohort recruited patients from 33 centres across North America, Europe, and Asia between 1999 and 2011. All patients were recruited within 15 months of confirming 4 American College of Rheumatology (ACR) Classification Criteria for systemic lupus erythematosus (SLE). Oral and parenteral GC use was described in detail and the associations between this use and a number of patient-dependent and patient-independent factors were explored using multivariable analyses. A consensus exercise was carried out amongst SLICC members to group damage items (from the SLICC/American Society of Rheumatology Damage Index) according to their likely association with GCs. Patterns of accrual of individual and grouped items were explored over 10 years of disease duration within the SLICC cohort.Results: We studied 1700 patients with a mean (SD) follow-up duration of 7.26 (3.82) years. 1365 (81.3%) patients received oral GCs at some time during the study and parenteral GCs were received between assessments in 4.26% (458/10745) of cases. GC use was strongly associated with treatment centre, age, race/ethnicity, sex, disease duration and disease activity. There was no change in the proportion of patients on GCs or the average doses of GC used over time. Over 10 years, 572 (35.1%) of all damage events occurred in the groups of items related to GCs. The annual incidence rates (AIR) of non-GC related events reduced over time whereas the AIR of GC-related events was similar in the first 2 years as in the 9th and 10th years.Conclusions: GCs remain a cornerstone in SLE management and there have been no significant changes in their use over the last 10-15 years. Whilst patient and disease factors contribute to the variation in GC use, between centre differences suggest that physician-related factors also contribute. GC-related damage occurs early and continues to accumulate over time, so that the relative contribution of GC-related events is higher later in disease. Early introduction of GC-sparing treatments and evidence based GC-algorithms are needed to inform GC use and minimise the risk of long-term damage in SLE.

Date of Award	1 Aug 2017
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Ian Bruce (Supervisor) & Mark Lunt (Supervisor)