Improvements in methodologies of both observational studies and clinical trials will advance knowledge concerning long-term use of <5 mg/day of prednisone. However, logistic, medical, and ethical considerations would require that multiple therapies be provided to patients to achieve best outcomes. Therefore, it may never be possible to isolate prednisone (or methotrexate, biological agent, physical therapy, or any single variable in a “reductionist” mode) in treatment of RA (or any chronic disease) over five years or longer. This limitation should not deter efforts to identify optimal strategies for low-dose prednisone to achieve better care and outcomes for patients with RA and all inflammatory rheumatic diseases.
A most important consideration in collecting and reporting observational data is to try to include all consecutive patients, to avoid patient selection. A database of consecutive patients provides data relevant to patient care that are not available through randomized controlled clinical trials.28 All data presented in this article concerning prednisone use over 25 years are based on only a simple one-page, two-sided MDHAQ, given by a receptionist to each patient at each visit while waiting to see the doctor. This practice requires minimal financial support or logistic complexities, and captures data concerning >99% of visits with simple “quality control” by doctor review with each patient, saving time for the doctor with information on the MDHAQ concerning self-report joint count, review of systems, and recent medical history.
Any rheumatologist can use this procedure to assess results of therapy over short or long periods. The best software and/or statistician cannot help clinicians learn about results of therapy if the data are not collected. Any visit without quantitative data is a lost opportunity.
Many patients with rheumatic diseases may have a prognosis for disability and mortality as severe as patients with primary cardiovascular or malignant diseases. It is up to rheumatologists to document that effective and safe therapies can reverse poor prognosis in usual clinical care. Of course, resources are needed to analyze databases. This need should not deter collection of an MDHAQ at each visit, which also prepares the patient for the visit, improves doctor–patient communication, and saves time for the doctor.
In conclusion, long-term low-dose prednisone, at doses of <5 mg/day, appears feasible and effective for many patients with RA, including initial dose of 3 mg/day and indefinite continuation. Recommendations for glucocorticoid therapy were developed initially during the 1950s, when glucocorticoids were the only available major antiinflammatory therapy. However, most patients with RA or other inflammatory rheumatic disease in contemporary care are (or should be) treated with concurrent methotrexate, other DMARDs, or cytotoxic therapies, and lower prednisone doses are adequate. Current practice may include doses of prednisone (much) higher than needed for many patients with any inflammatory rheumatic disease.
