Attitude of rheumatoid arthritis patients to treatment with oral corticosteroids

E. Morrison, D. Crosbie and H. A. Capell1

Department of Rheumatology, Southern General Hospital and 1Centre for Rheumatic Disease, Royal Infirmary, Glasgow, UK.

Correspondence to: E. Morrison, Department of Rheumatology, Southern General Hospital, South Glasgow University Hospitals NHS Trust, 1345 Govan Road, Glasgow G51 4TF, UK. E-mail: elaine.morrison{at}SGH.scot.nhs.uk


    Abstract
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1. Patient attitude...
 References
 
Objective. To assess the attitudes of rheumatoid arthritis (RA) patients to oral corticosteroid treatment, factors influencing these views and their likely clinical impact.

Methods. A cross-sectional survey of 158 consecutive RA out-patients was carried out at two centres over 2 weeks. Demography, disease duration, function [Health Assessment Questionnaire (HAQ)], erythrocyte sedimentation rate (ESR), years of formal education and social deprivation index were noted. Prospective recruitment into the multicentre West of Scotland Early Rheumatoid Arthritis Corticosteroid Trial (WOSERACT) was monitored and reasons for refusal to participate (when available) were noted at three of the centres.

Results. Forty-eight (32%) patients were willing to be treated with oral corticosteroid and 100 (68%) were not. The former were older (P = 0.002), had a higher ESR (P = 0.007), poorer function (P = 0.001) and greater previous exposure to disease-modifying anti-rheumatic drugs (P = 0.013). Ninety patients refused to participate in WOSERACT, in 46 cases (40 female, 6 male) the reason being concerns about corticosteroids.

Conclusions. This study shows a high level of concern about and refusal of corticosteroid treatment in RA, due mainly to patient concerns about adverse effects. Rheumatologists need to be aware of these attitudes as they are likely to affect prescribing.

KEY WORDS: Rheumatoid arthritis, Corticosteroid treatment, Patient attitudes, Corticosteroid side-effects, Study recruitment.


    Introduction
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1. Patient attitude...
 References
 
Since the inception of their use in rheumatoid arthritis (RA) [1], oral corticosteroids have drawn mixed reviews [211]. Rheumatologists remain ambivalent, balancing the benefits of short-term disease control [12] against concerns about longer-term toxicity [13]. The place of oral corticosteroids in the management of RA remains controversial [1416].

Patients have become aware of this debate. However, their views are also informed by the experiences of individuals known to them who have received corticosteroids and by the lay press [17]. In clinical practice, patients often voice concerns about corticosteroid side-effects and many hold very definite views about these drugs and their use.

Good practice in the management of chronic disease involves a partnership with patients, and their views about treatment affect prescribing [18]. Patient attitude to oral corticosteroid therapy in RA is, therefore, important and an issue that has not been addressed previously by rheumatologists.

In this study, we sought to assess the attitudes of RA patients to oral corticosteroid treatment, factors influencing these views and their likely clinical impact.


    Methods
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1. Patient attitude...
 References
 
A cross-sectional survey (see Appendix 1 for the patient questionnaire that was used) of 158 consecutive RA out-patients was carried out at two centres over 2 weeks to assess patient attitude to treatment with, and their knowledge of, corticosteroids in RA. Patient demographics, disease duration, function as measured by the Health Assessment Questionnaire (HAQ) [19], erythrocyte sedimentation rate (ESR), years of formal education and social deprivation index [20] were recorded.

Prospective recruitment of early RA patients into the multicentre West of Scotland Early Rheumatoid Arthritis Corticosteroid Trial (WOSERACT) was monitored and reasons for refusal to participate (when available) were noted at three centres. This information was collected in an effort to determine whether patient attitudes to corticosteroid treatment would influence their choice of therapy in clinical practice.


    Results
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1. Patient attitude...
 References
 
Data for 148 patients in the cross-sectional study are shown in Table 1. Eight patients, currently or previously treated with oral corticosteroid were excluded from the analysis and two withdrew their consent. The YES group are those who were willing to accept treatment with oral corticosteroid, and the NO group are those who would not.


View this table:
[in this window]
[in a new window]
 
TABLE 1. Cross-sectional study patient characteristics [median (range)]

 
Forty-eight (32%) patients were willing to be treated with oral corticosteroid whilst 100 (68%) were not. The former were older (P = 0.002), had a higher ESR (P = 0.007), poorer function (P = 0.001) and greater prior exposure to disease-modifying anti-rheumatic drugs (DMARDs) (P = 0.013). No difference in disease duration, years of formal education or social deprivation index was noted between the two groups.

Thirty-eight patients believed that oral cortico-steroids were helpful in the treatment of RA, eight felt there was no benefit and 102 did not know. Table 2 shows corticosteroid side-effects listed by patients. Whilst the YES group rated their knowledge about corticosteroid higher than the NO group (P = 0.007), no difference was noted between the groups in terms of the number of side-effects listed or the number of correct side-effects listed.


View this table:
[in this window]
[in a new window]
 
TABLE 2. Corticosteroid side-effects listed by patients

 
One hundred and sixty-seven RA patients (median disease duration 1 yr) were recruited to WOSERACT to evaluate treatment with low-dose prednisolone and sulphasalazine vs sulphasalazine alone. One hundred and seventeen of these patients were enrolled in three centres where reasons for refusal to participate were noted with patient permission. Ninety patients declined to participate, 46 (40 female and six male) for reasons related to corticosteroid use. In the whole study population (n = 167), the gender ratio was 1.8 females to 1 male.


    Discussion
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1. Patient attitude...
 References
 
In our cross-sectional survey, a significant number of RA patients were unwilling to consider treatment with oral corticosteroid. Older, more disabled patients with more active disease were more likely to accept this form of therapy. This may have implications for corticosteroid prescription in early disease, when patients are likely to be younger and less disabled. In fact, our prospective study of low-dose corticosteroid treatment in early RA (WOSERACT) showed that recruitment was adversely affected by patient concerns about oral corticosteroid therapy.

In our patient survey, we noted no difference between the YES and NO groups in social deprivation index or years of formal education, suggesting that the decision to take (or not) oral corticosteroid is driven by disease-related rather than socioeconomic factors.

The majority of RA patients answering the questionnaire did not know whether oral corticosteroids were beneficial in RA but were able to list a number of adverse effects. This suggests that patients do have some prior knowledge of, and perhaps some preconceived ideas about, this form of therapy. It could be argued that their decisions regarding corticosteroid treatment were influenced by these factors rather than by balanced discussion with medical or nursing staff. However, this is not borne out by our prospective data. At recruitment to WOSERACT, patients were counselled by rheumatology nurse metrologists about the potential benefits and risks of low-dose corticosteroids in RA, and despite this a significant number of those who declined to participate, in the three centres recording this (n = 90), did so due to concerns about corticosteroid (n = 46, i.e. 51%). We did not record whether counselling changed attitudes.

The majority of patients refusing to participate in WOSERACT were females, which led to a rather skewed gender ratio (female:male, 1.8:1) in this study compared with previous DMARD studies carried out by our centre, which have typically shown a ratio of 3:1 [21]. Interestingly, the gender ratio was exactly the same in the Arthritis and Rheumatism Council low-dose corticosteroid study [9] (1.8:1), suggesting that they too recruited fewer females than may have been expected, although reasons for refusal were not indicated. Similar findings were also noted in a comparative study of step-down prednisolone, methotrexate and sulphasalazine vs sulphasalazine alone in early RA, in which the gender ratio was 1.4:1 [11]. These findings contrast not only with our DMARD studies but also with major studies from elsewhere [22, 23] (summarized in Table 3).


View this table:
[in this window]
[in a new window]
 
TABLE 3. Sex ratio in RA studies with and without corticosteroid use

 
The data from our prospective study (WOSERACT) regarding those patients declining to participate due to concerns about corticosteroid do not contain specific details about their reasons for doing so. However, the results of our cross-sectional survey indicate that the majority of patients listed weight gain and bloating as side-effects, and it is possible that similar fears, especially among female patients, existed in our prospective population and influenced their choice of therapy.

Clearly, attitudes of RA patients to treatment with oral corticosteroid, in both early and late disease, are highly relevant and a feature rheumatologists need to be aware of as these attitudes are likely to influence our clinical practice in terms of both patient counselling and prescription.


    Appendix 1. Patient attitude questionnaire
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1. Patient attitude...
 References
 
Patient attitudes to oral corticosteroid use in rheumatoid arthritis
Please rate your current knowledge of steroid tablets (prednisolone) on a scale of 1 to 10

(1 = poor, 5 = average, 10 = good)

1———————–5———————–10

Please list any side-effects of steroid tablets that you are aware of:

Do you think that steroid tablets are useful in the treatment of rheumatoid arthritis?

YES  NO  DO NOT KNOW

Have you ever taken steroid tablets for your arthritis?

YES  NO

If YES, for how long?

Would you be willing to take steroid tablets for your arthritis?

YES  NO

Please return to a member of staff before leaving the clinic. Thank you.


    Acknowledgments
 
We thank the WOSERACT study group, A. Tierney for typing the manuscript, D. McKnight for statistical analysis, D. McGhee, R. Hampson and D. Creran for nursing and metrology support, and R. Madhok and S. M. Fraser for allowing us to recruit their patients.

Conflicts of interest

The authors have declared no conflict of interest.


    References
 Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Appendix 1. Patient attitude...
 References
 

  1. Hench PS, Kendall EC, Slocumb CH, Polley HF. The effect of a hormone of the adrenal cortex (17-hydroxy-11-dehydrocortisone: compound E) and of pituitary adrenocorticotrophic hormone on rheumatoid arthritis. Preliminary report. Proc Staff Meet Mayo Clin 1949;24:181–97.[ISI]
  2. Empire Rheumatism Council. Multicentre controlled trial comparing cortisone acetate and acetyl salicylic acid in the longterm treatment of rheumatoid arthritis. Results of three years treatment. Ann Rheum Dis 1957;16:277–89.[ISI]
  3. Joint Committee of the Medical Research Council and the Nuffield Foundation. A comparison of prednisolone with aspirin or other analgesics in the treatment of rheumatoid arthritis. Ann Rheum Dis 1959;18:173–87.[ISI]
  4. Bernsten CA, Freyberg RH. Rheumatoid patients after five or more years of corticosteroid treatment: A comparative analysis of 183 cases. Ann Intern Med 1961;54:938–53.[ISI]
  5. Liebling MR, Leib E, McLaughlan K et al. Pulse methylprednisolone. A double-blind cross-over trial. Ann Intern Med 1981;94:21–6.[ISI][Medline]
  6. Corkill MM, Kirkham BW, Chikanza IC, Gibson T, Panayi GS. Intramuscular depot methylprednisolone induction of chrysotherapy in rheumatoid arthritis: A 24 week randomised controlled trial. Br J Rheumatol 1990;29:274–9.[ISI][Medline]
  7. Hansen TM, Kryger P, Elling H et al. Double blind placebo controlled trial of pulse treatment with methylprednisolone combined with disease modifying drugs in rheumatoid arthritis. Br Med J 1990;301:268–70.
  8. Van Gestel AM, Laan RFJM, Haagsma CJ, Van de Putte LBA, Van Reil PLCM. Oral steroids as bridge therapy in rheumatoid arthritis patients starting with parenteral gold. A randomised double-blind placebo-controlled trial. Br J Rheumatol 1995;34:347–51.[ISI][Medline]
  9. Kirwan JR and the Arthritis and Rheumatism Council Low-Dose Glucocorticoid Group. The effect of glucocorticoids on joint destruction in rheumatoid arthritis. N Engl J Med 1995;333:142–6.[Abstract/Free Full Text]
  10. Ciconelli RM, Ferraz MB, Visioni RA, Oliveira LM, Atra E. A randomised double-blind controlled trial of sulphasalazine combined with pulses of methylprednisolone or placebo in the treatment of rheumatoid arthritis. Br J Rheumatol 1996;35:150–4.[ISI][Medline]
  11. Boers M, Verhoeven AC, Markusse HM, van de Laar MAFJ, Westhovens R, van Denderen JC et al. Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis. Lancet 1997;350:309–18.[CrossRef][ISI][Medline]
  12. Criswell LA, Saag KG, Sems KM et al. Moderate-term, low-dose corticosteroids for rheumatoid arthritis (Cochrane Review). The Cochrane Library, Issue 1, 2002.
  13. Saag KG, Koehnke R, Vladwell JR, Brasington R, Burmeister LF, Zimmerman B. et al. Low dose long-term corticosteroid therapy in rheumatoid arthritis: An analysis of serious adverse events. Am J Med 1994; 96:115–23.[ISI][Medline]
  14. Morrison E, Capell H. Corticosteroids in the management of rheumatoid arthritis. Br J Rheumatol 1996; 35:1–4.[ISI][Medline]
  15. Boers M. The case for corticosteroids in the treatment of early rheumatoid arthritis. Br J Rheumatol 1999;38:95–7.[CrossRef]
  16. Morrison E, Capell H. Corticosteroids in rheumatoid arthritis—the case against. Br J Rheumatol 1999;38: 97–100.[CrossRef]
  17. Leake J. Thousands fight for steroid justice. The Sunday Times, 27 August 1995.
  18. Holman H, Lorig K. Patients as partners in managing chronic disease. Br Med J 2000;320:526–7.[Free Full Text]
  19. Kirwan JR, Reeback JS. Stanford Health Assessment Questionnaire modified to assess disability in British patients with rheumatoid arthritis. Br J Rheumatol 1986;25:206–9.[ISI][Medline]
  20. Carstairs V, Morris R. Deprivation and health in Scotland. Aberdeen: Aberdeen University Press, 1991.
  21. McEntegart A, Porter D, Capell HA, Thomson EA. Sulphasalazine has a better efficacy/toxicity profile than auranofin—Evidence from a 5 year prospective trial J. Rheumatol 1996;23:1887–90.
  22. Smolen JS, Kalden JR, Scott DL et al. and the European Leflunomide Study Group. Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a double-blind, randomised, multicentre trial. Lancet 1999;353:259–66.[CrossRef][ISI][Medline]
  23. O’Dell JR, Leff R, Paulsen G et al. Treatment of rheumatoid arthritis with methotrexate and hydroxychloroquine, methotrexate and sulphasalazine, or a combination of the three medications. Arthritis Rheum 2002;46:1164–70.[CrossRef][ISI][Medline]
Submitted 29 August 2002; Accepted 3 March 2003