A recent study published in JAMA Network Open has found that restricting the use of oral corticosteroids to a maximum of 90 days can help mitigate adverse effects in adults suffering from atopic dermatitis (AD), a chronic inflammatory skin condition.
Atopic dermatitis affects approximately 2.1% to 4.9% of adults worldwide, with up to 10% of those with moderate to severe cases requiring medication. Despite clinical guidelines recommending limited short-term use of corticosteroids, many patients continue to use them long-term, which can lead to significant complications. However, research exploring the long-term effects of these medications in AD patients remains limited.
The study utilized data from the South Korean Health Insurance Review and Assessment Service (HIRA) database, covering a period from January 1, 2012, to October 31, 2021. Researchers analyzed health records of patients diagnosed with AD who were prescribed oral corticosteroids between January 1, 2013, and October 31, 2020. The study was approved by the institutional review board of Sungkyunkwan University, which waived the need for informed consent due to the anonymized nature of the data.
The cohort included patients aged 18 and older who were not diagnosed with any immune-mediated inflammatory diseases or specific adverse outcomes. The study defined long-term use as exceeding 30 or 90 days per year with a daily dose of more than 5 mg of prednisolone equivalent. Researchers adjusted for various factors, including demographics, comorbidities, and AD severity, using multivariable conditional logistic regression to estimate adjusted odds ratios for adverse events (AEs).
The analysis included 1,025,270 AD patients who received at least one prescription for oral corticosteroids during the study window. Of these, 164,809 patients (average age 39.4 years; 56.9% female) were matched with 328,303 controls (average age 39.3 years; 56.9% female) in a 1:2 ratio. The matching criteria included entry date, sex, age, follow-up duration, and AD severity, ensuring most covariates were balanced.
Among the cohort, 3.4% of cases (5,533 individuals) and 3.2% of controls (10,561 individuals) were exposed to corticosteroids for over 30 days, while 0.4% of both groups were exposed for over 90 days. The study found no increased risk of AEs associated with corticosteroid use exceeding 30 days (adjusted odds ratio [AOR] 1.00; 95% confidence interval [CI], 0.97-1.04). However, use beyond 90 days was linked to an 11% increased risk of composite AEs (AOR 1.11; 95% CI, 1.01-1.23). Each additional year of long-term exposure (over 90 days) correlated with a slight increase in the risk of AEs (AOR 1.06; 95% CI, 1.00-1.13).
Specific risks associated with corticosteroid use for over 30 days included hypertension (AOR 1.09; 95% CI, 1.03-1.15), avascular necrosis (AOR 2.56; 95% CI, 1.82-3.62), and cataracts (AOR 3.22; 95% CI, 1.05-9.85). For those using corticosteroids for more than 90 days, increased risks were noted for fractures (AOR 1.22; 95% CI, 1.05-1.42) and hyperlipidemia (AOR 1.16; 95% CI, 1.03-1.30). Additionally, the risk of myocardial infarction (AOR 2.22; 95% CI, 1.17-4.22) and avascular necrosis (AOR 6.88; 95% CI, 3.53-13.42) was significantly elevated.
Subgroup analyses showed that the risk of composite AEs associated with long-term corticosteroid use was consistent across sex, age, and AD severity. Sensitivity analyses confirmed the robustness of these findings.
Conclusions
The study identified a significant cohort of 164,809 cases and 328,303 controls with atopic dermatitis. While long-term use of oral corticosteroids exceeding 30 days was not significantly linked to increased adverse outcomes, usage beyond 90 days showed a notable risk increase for several complications, including fractures, myocardial infarction, hyperlipidemia, avascular necrosis, hypertension, and cataracts. These findings align with previous research on asthma patients, reinforcing the association between corticosteroid use and various adverse effects on bone, metabolic, cardiovascular, and ocular health. The results suggest that limiting oral corticosteroid therapy to 90 days may be a prudent strategy to enhance patient safety in managing atopic dermatitis.
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