Clinical Year in Review: 2023

Clinical Updates in Rheumatology Presented at ACR Convergence 2023

Philip Seo, MD, MHS

SAN DIEGO—At ACR Convergence 2023, Philip Seo, MD, MHS, associate professor of medicine, Johns Hopkins University, Baltimore, presented a humorous and engaging overview of clinical updates in rheumatology. This article summarizes many of the articles he discussed.

Updates to Key Trials from 2022

Dr. Seo began discussing updates to two sentinel trials discussed in the 2022 Year in Review: the ORAL Surveillance study and the GLORIA trial.^1-3

The ORAL study was mandated by the U.S. Food & Drug Administration (FDA) to look at the safety of tofacitinib in patients older than 50 with one cardiac risk factor and active rheumatoid arthritis (RA) despite treatment with methotrexate. Referencing the original trial, Dr. Seo noted, “This is the table that launched a thousand studies. Ever since this study, we’ve been trying to explain why tofacitinib is associated with an increased risk of cardiovascular events, venous thromboembolic events and malignancy. And these [same investigators] may have provided us with an answer.”

The ORAL Surveillance investigators conducted a post-hoc analysis that identified subpopulations with different relative risk with tofacitinib vs. tumor necrosis factor inhibitors (TNFi).⁴ Patients older than 65 with a current or prior long-time smoking history were at higher risk with tofacitinib compared with TNFi, whereas those younger than 65 who didn’t smoke weren’t. Dr. Seo remarked, “[The investigators] possibly managed to highlight a group of patients who can use tofacitinib and, by extension, other Janus kinase inhibitors relatively safely.”

The GLORIA trial demonstrated that the addition of prednisolone 5 mg daily to standard-of-care therapies in people with active RA older than 65 decreased disease activity and joint damage.³ The tradeoff was a 24% increased risk of mostly non-severe adverse events. This year, a follow-up study looked at what happened when the same patients were tapered off prednisolone over a period of three months.⁵ There was a concordant small increase in disease activity when patients were tapered, but interestingly, no one developed adrenal insufficiency.

Dr. Seo noted, “I think there are two messages here. First, if you have an older patient on low dose glucocorticoids for two years, we shouldn’t be afraid to taper. You won’t see adrenal insufficiency as a result. However, if you have a patient with low disease activity on chronic low-dose glucocorticoids, tapering is probably not the best strategy, since it might induce a disease flare.”