Glucocorticoid Use in Rheumatoid Arthritis Management Focus of Ongoing Debate

“This is an addictive drug,” says Dr. Russell. “If I refuse to give it to patients after bridging therapy, they may try to go back to their family doctor to obtain a prescription.” The answer to this dilemma, he says, is to reach out to physician colleagues in the community, and to increase one’s own availability for referrals so patients can be treated appropriately and early in the course of their disease.

Awaiting Resolution

Dr. Saag admits that there is a paucity of well-conducted clinical trials that would establish the best practices for use of steroids in RA. EULAR has addressed the question, and Dr. Saag reports that the ACR is on target to release recommendations regarding use of low-dose glucocorticoids in 2015.¹¹

Dr. Boers, who was recently funded by the EU Commission in the Horizon 2020 program to conduct a large pragmatic trial on low-dose prednisolone in elderly RA patients, thinks addressing the topic is an important first step for the ACR. He contends that there is now ample evidence of the benefits of the therapy and growing evidence that inflammation itself is causing some of the side effects traditionally attributed to glucocorticoids. Example: An Amsterdam study showed over half of patients with early RA had impaired glucose tolerance or even undiagnosed type 2 diabetes before initiating therapy with glucocorticoids. “As expected, some of these patients progressed to overt diabetes upon exposure to a week of high-dose (30 or 60 mg/d) prednisolone. However, a similar number actually normalized their glycemic profile, so that on average glucose tolerance was unchanged after one week of treatment.”

Similarly, active RA itself induces an atherogenic blood lipid profile and bone loss, effects traditionally ascribed to glucocorticoids. He concludes, “I think the tragedy is that people are being stopped too early because of guidelines saying ‘use as briefly as possible and at the lowest possible dose,’ and that their disease is not going into remission.”

Gretchen Henkel is a medical journalist based in California.

References

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