The first suggestion that glucocorticoids, in addition to suppressing inflammation, might be able to halt the underlying progression of destructive erosions in RA was in a study published in 1959, but my own interest in this area was stimulated by Dr. John Decker, one of the fathers of rheumatology in the U.S., who encouraged me to try to clarify the role of glucocorticoid therapy in RA.5 We set up the first of several studies carried out by authors from different countries that proved conclusively that glucocorticoids are the strongest disease-modifying agent and can substantially hold back the destructive process of RA.6 So why are they not recommended by the ACR in their guidelines for the treatment of newly diagnosed disease? Because glucocorticoids, “were not within the purview” of the recommendations or of a recent update, even though it was recognized that “these may be important components of RA treatment.”7 How could this be? What reason might there be for omitting consideration of a treatment shown so clearly to be beneficial?
Recent Evidence
In a recent evidence based–medicine project at our medical school, 260 undergraduate students halfway through their course took on the task of finding the best evidence for treating newly diagnosed RA, and comparing this to published guidelines. In one afternoon, and with only access to the Internet, each other, and a few facilitating teachers in support, they concluded that all newly diagnosed patients should be offered the opportunity to take glucocorticoids, a recommendation also promulgated by the UK National Institute for Health and Clinical Excellence. The students were astonished that the ACR guidelines omitted this treatment, and asked if ACR guidelines for other diseases are likely to be equally deficient.
Some will be overly concerned with the possibility of adverse effects. Such concerns do not sit well with current widespread use, but neither are they supported by the literature. Recent systematic reviews have not found evidence of serious consequences of short- or medium-term treatment with relatively low doses of glucocorticoids. Indeed, in many randomized controlled trials, the frequency of adverse effects is lower than in the comparator arm, perhaps because glucocorticoids protect against the adverse effects of other treatments used at the same time such as methotrexate.
Some clinicians might consider an emphasis on “tight control” treatment strategies would be a more worthy effort, even though these have not yet been shown to be cost effective. However, adding glucocorticoids to a tight control strategy undoubtedly improves outcome even further. In an editorial commenting on the paper that reports this finding, I suggested that combination therapy including glucocorticoids is the new gold standard for early treatment in RA—a position I continue to advocate here.8
