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Glucocorticoids in RA
Reconsidering the Role of Glucocorticoids in Rheumatoid Arthritis Management

Released: June 09, 2016

Expiration: June 08, 2017

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Almost every decade has seen a change in our perspective on the use of glucocorticoids in rheumatoid arthritis (RA). This history dates back to 1950, when the Nobel Prize in Physiology or Medicine was awarded to Philip Hench and colleagues for their discoveries of the structure and function of the hormones of the adrenal complex. At that time, it was widely publicized that the first applications of glucocorticoids to a chronic inflammatory disorder such as RA could have remarkable benefits for the signs and symptoms of the disease, including tender and swollen joints. However, over time, it became appreciated that the progressive structural damage that can be associated with RA was not significantly abated by the use of glucocorticoids. Although patients felt better, glucocorticoids did not affect the destructive phase of the disease. Since then, we have been increasingly aware of the potential toxicities of glucocorticoids, which increase with higher doses and longer-term use.

Updated Guidance
Most recently, the American College of Rheumatology (ACR) guideline has been updated for the first time to include recommendations on glucocorticoids and now encourages us to reconsider their use. It provides direct and unambiguous advice on the use of low-dose glucocorticoids as bridge therapy for patients with moderate to high disease activity who are beginning or switching RA therapy and for those experiencing RA disease flares. The recommendation is that glucocorticoids should be administered at ≤ 10 mg/day of prednisone (or equivalent) for less than 3 months. Moreover, the guideline recommends that glucocorticoids should be used at the lowest possible dose and for the shortest possible duration. Essentially, glucocorticoids can be considered to help patients feel and function better while initiating other therapies that are more likely to lower disease activity or induce remission. Notably, the guideline states that this recommendation is conditional due to a generally low quality of evidence and lack of long-term safety studies with glucocorticoids.

In Defense of the Guideline
For rheumatologists, this recommendation seems controversial because most of us have been cautioned to avoid steroids in our patients due to the adverse events. I would offer that the guideline is carefully advising against long-term use of glucocorticoids. Certainly, we want to avoid risking steroid dependence by incorporating these agents into a long-term treatment regimen. However, if we can provide our patients some relief with a short-term, low-dose glucocorticoid while evaluating if a new remittive therapy is providing benefit, I would argue that this is advantageous for the patient, who is more likely to remain adherent to treatment in the long run following an early positive experience. Moreover, this strategy is good for the doctor–patient relationship, in which both parties have a vested interest in making the patient feel better.

My Approach
In my practice, I prescribe low-dose, short-term glucocorticoids for patients who are having difficulty functioning, including those who experience morning stiffness and systemic involvement and who have more than 10 joints affected. I start glucocorticoids at the same time as initiating oral weekly methotrexate (for those beginning first-line RA treatment) or switching to a biologic or Jak inhibitor (for those who have had an inadequate response to methotrexate). Subsequently, my goal is to taper off the glucocorticoid generally within 2-4 weeks while evaluating if the remittive therapy is beneficial. I would also consider adding low-dose, short-term glucocorticoids for a patient experiencing a disease flare, although I would carefully consider if systemic steroids are necessary. In cases of disease flare where only a few joints are involved, I would favor other strategies for relief, such as local injections. Of importance, I avoid glucocorticoids in patients with a history of glucose intolerance or a diagnosis of diabetes and those who have experienced adverse events with previous steroid use.

Your Thoughts
How has the recent guideline update affected your use of glucocorticoids in patients with RA? I invite readers to post their thoughts and opinions in the comments section below. To learn more about RA management, watch my case-based conversation with Sergio Schwartzman, MD, and check back soon for additional ClinicalThought™ commentaries.

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How do you currently use low-dose, short-term glucocorticoids when managing patients with RA?
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