Damage in systemic lupus erythematosus and its association with corticosteroids

Objective. To evaluate the association between corticosteroid use and organ damage in patients with systemic lupus erythematosus (SLE). Method. The occurrence and date of organ damage, as measured by the Systemi c Lupus International Collaborating Clinics/American College of Rheumatolog y Damage Index, were determined for 539 patients enrolled in the Hopkins Lu pus Cohort Study. The risk of damage associated with the cumulative prednis one dose, high-dose prednisone (greater than or equal to 60 mg/day for grea ter than or equal to 2 months), and pulse methylprednisolone (1,000 mg intr avenously for 1-3 days) was estimated using Cox proportional hazards regres sion analyses, controlling for age, race, and sex. Risk estimates for the c umulative prednisone dose were based on a reference dose of 36.5 gm (e.g., 10 mg of prednisone daily for 10 years [or equivalent]). Results. The cumulative prednisone dose was significantly associated with t he development of osteoporotic fractures (relative risk [RR] 2.5, 95% confi dence interval [95%, CI] 1.7, 3.7), symptomatic coronary artery disease (RR 1.7, 95% CI 1.1, 2.5), and cataracts (RR 1.9, 95% CI 1.4, 2.5). Each intra venous pulse was associated with a small increase in the risk of osteoporot ic fractures (RR 1.3, 95% CI 1.0, 1.8); however, this result failed to reac h statistical significance (P = 0.07). Each 2-month exposure to high-dose p rednisone was associated with a 1.2-fold increase in the risk of both avasc ular necrosis (95% CI 1,I, 1.4) and stroke (95% CI 1.0, 1.5). Conclusion. SLE patients receiving long-term prednisone therapy were at sig nificant risk of morbidity due to permanent organ damage. Additional resear ch is required to determine the relative contributions of SLE disease activ ity and corticosteroids to the pathogenesis of specific types of organ dama ge. Furthermore, new steroid-sparing therapies are needed in order to treat disease activity and minimize cumulative and high-dose prednisone exposure .