Glucocorticoid Use Is Associated With an Increased Risk of Hypertension

Ruth E. Costello; Belay B. Yimer; Polly Roads; Meghna Jani; William G. Dixon

Disclosures

Rheumatology. 2021;60(1):132-139. 

In This Article

Abstract and Introduction

Abstract

Objectives: Patients with RA are frequently treated with glucocorticoids (GCs), but evidence is conflicting about whether GCs are associated with hypertension. The aim of this study was to determine whether GCs are associated with incident hypertension in patients with RA.

Methods: A retrospective cohort of patients with incident RA and without hypertension was identified from UK primary care electronic medical records (Clinical Practice Research Datalink). GC prescriptions were used to determine time-varying GC use, dose and cumulative dose, with a 3 month attribution window. Hypertension was identified through either: blood pressure measurements >140/90 mmHg, or antihypertensive prescriptions and a Read code for hypertension. Unadjusted and adjusted Cox proportional hazards regression models were fitted to determine whether there was an association between GC use and incident hypertension.

Results: There were 17 760 patients in the cohort. A total of 7421 (42%) were prescribed GCs during follow-up. The incident rate of hypertension was 64.1 per 1000 person years (95% CI: 62.5, 65.7). The Cox proportional hazards model indicated that recent GC use was associated with a 17% increased hazard of hypertension (hazard ratio 1.17; 95% CI: 1.10, 1.24). When categorized by dose, only doses above 7.5 mg were significantly associated with hypertension. Cumulative dose did not indicate a clear pattern.

Conclusion: Recent GC use was associated with incident hypertension in patients with RA, in particular doses ≥7.5 mg were associated with hypertension. Clinicians need to consider cardiovascular risk when prescribing GCs, and ensure blood pressure is regularly monitored and treated where necessary.

Introduction

RA is a chronic inflammatory condition, affecting around 1% of the general population.[1] Patients with RA are at an increased risk of all-cause mortality compared with the general population.[2] Cardiovascular (CV) disease is a major driver of this: a meta-analysis showed that patients with RA have a 50% increased risk of CV mortality compared with the general population.[3] This increased risk of CV disease[4] is due not only to traditional risk factors such as smoking and hypertension, but also to disease-related factors such as disease activity, which increases inflammation,[5,6] and potentially to medication used to manage RA, for example NSAIDs[7] or glucocorticoids (GCs).

GCs are frequently prescribed in RA, with up to two-thirds of patients with RA ever prescribed GCs.[8,9] This reflects their powerful anti-inflammatory effects, yet their use is associated with a wide range of adverse effects, such as fractures, infections, insomnia and weight gain.[10] Another less well studied but widely cited side effect of GCs is hypertension. Hypertension has been captured as one of many adverse events in clinical trials.[11–14] In placebo controlled trials of patients with a variety of rheumatic conditions (RA, polymyalgia rheumatica, GCA) there were 3–28 hypertension events per 100 patient years in those using chronic medium dose GCs (7.5 to <30 mg/day). However, the range of reported hypertension events is wide compared with other GC adverse events.15 There have been very few studies focussed specifically on GC-induced hypertension in RA. Observational studies specifically investigating hypertension and GC use have had conflicting results: some studies have described medium to high dose GCs being associated with hypertension,[16,17] while other studies found no association.[18,19] As hypertension may further increase CV risk, it is important to evaluate whether GCs increase the risk of hypertension and if so, how this might relate to dose. Therefore, the aim of this study was to determine whether GCs are associated with increased risk of incident hypertension in a cohort of patients with incident RA.

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