By Nicole MacKee
Strict blood pressure monitoring is essential among patients taking oral glucocorticoids, according to researchers who have found that cumulative steroid dose is associated with an increased risk of hypertension.
Their UK record-linkage cohort study, published in the Canadian Medical Association Journal, examined the association between oral glucocorticoid dose and the development of hypertension in 71,642 patients with one of six chronic inflammatory diseases. The six inflammatory diseases were inflammatory bowel disease, systemic lupus erythematosus, polymyalgia rheumatica, rheumatoid arthritis, giant cell arteritis and vasculitis.
The researchers found that almost 35% of participants (24,896) developed hypertension during the median follow up of 6.6 years. The incidence rate of hypertension was 46.7 per 1000 person years.
The incidence rate increased in line with higher cumulative doses of glucocorticoid, increasing from 44.4 per 1000 person-years in periods of nonuse to 55.6 per 1000 person-years with cumulative doses of 3055 mg or more. The average prescribed cumulative dose was 3205 mg prednisolone equivalent dose.
Although cumulative dose associations were shown in all six diseases studied, no dose response effects were found for daily doses.
‘Given that glucocorticoids are widely prescribed, the associated health burden could be high,’ the researchers concluded.
Associate Professor George Mangos, UNSW Clinical Academic at St George Clinical School, Sydney, said although the association between glucocorticoids and hypertension had been known for several decades, particularly among patients with Cushing syndrome (endogenous glucocorticoid excess), this powerful study provided clarity on the prevalence of hypertension among patients prescribed oral steroids, and highlighted the cumulative dose-response association.
‘Anyone who is on a prolonged course of glucocorticoids needs to have their blood pressure checked regularly, both during the course of medication and for a year or two afterwards,’ Associate Professor Mangos told Medicine Today.
‘If a patient is on these drugs chronically or takes repeated courses, they need close attention paid not only to their blood pressure but to other vascular risk factors. Steroids can result in increased glucose and cholesterol levels, and they are also associated with weight gain. All the negative consequences of ageing and a sedentary lifestyle happen in an accelerated way with excess glucocorticoid.’
Associate Professor Mangos said research he had conducted with colleagues in 2002 had shown that glucocorticoid activity disrupted the nitric oxide system resulting in elevated blood pressure (J Hypertens 2002; 20: 1035-1043).
‘Steroids can lead to a functional nitric oxide deficiency and oxidative stress in the body, which may be the main mechanism,’ he said.
CMAJ 2020; 192: E295-301; doi: 10.1503/cmaj.191012.