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Why Oral Corticosteroids Should Not be Used in Patients with Rheumatoid Arthritis

Anthony S. Russell, MA, MB, BCHIR  |  Issue: April 2013  |  April 1, 2013

As my colleagues and I once observed, “the decision to institute steroid therapy emanates in part from a simple desire to rapidly alleviate patients’ symptoms.”19 This “quick fix” can prove misleading to both patient and doctor regarding the need for longer-term DMARD control of the RA. The published guidelines of the ACR recommend DMARD therapy if active disease is present.20 A patient whose PCP recently prescribed steroids for early RA—permitted in the guidelines—could have their disease activity inappropriately masked so they are not started on DMARDs—or even worse, not referred to a rheumatologist until damage is done.

In summary, we are using a drug with impressive long-term toxicity and without demonstrable symptomatic benefit after one year of use even at 10 mg per day. All of this for a demonstrated benefit of four Sharp score units at four years!

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I am reminded of a quote from Lewis Carroll’s Through the Looking Glass: “I didn’t say it was good for you,” the king replied. “I said that there was nothing like it.”


Dr. Russell is professor of medicine at the University of Alberta in Edmonton.

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References

  1. Kirwan JR, and the arthritis and rheumatism council low dose glucocorticoid study group. The effect of glucocorticoids on joint destruction in. N Engl J Med. 1995;333:142-146.
  2. Hafstrom I, Albertsson,K, Boonen A, van derHeijde D, Landewe R, Svenson B, for the BARFOT study group. Remission achieved after 2 years treatment with low-dose prednisolone in addition to disease-modifying anti-rheumatic drugs in early rheumatoid arthritis is associated with reduced joint destruction after 4 years: An open 2 year continuation study. Ann Rhem Dis. 2009;68:508-513.
  3. Bakker MF, Jacobs JWG, Websing PMJ, et al. Low-dose prednisone inclusion and methotrxate based tight control strategy for early rheumatoid arthritis. Ann Int Med. 2012:156:329-339.
  4. Van-Everdingen AA, Jacobs JWG, van Reesema DRS, Bijlsma WJ. Low-dose prednisone therapy for patients with early active rheumatoid arthritis: Clinical efficacy, disease modifying properties and side effects: A randomized double-blind placebo-controlled clinical trial. Ann Int Med. 2002;136:1-12.
  5. Scott DL, Coulton BL, Chapman JH, Bacon PA, Popert AJ. The long-term effects of treating rheumatoid arthritis. J R Coll Physicians Lond. 1983;17:79-85.
  6. Pincus T, Callahan LF. Taking mortality in rheumatoid arthritis seriously: Predictive markers, socioeconomic status and co-morbidity. J Rheumatol. 1986;13:841-845.
  7. Corbett M, Dalton S, Young A, Silman A, Shipley M. Factors predicting death, survival, and functional outcome in a prospective study of early rheumatoid disease over 15 years. Br J Rheumatol. 1993;32:481-484.
  8. Criswell LA, Henke CJ. What explains the variation among rheumatologists in their use of prednisone and second line agents for the treatment of rheumatoid arthritis. J Rheumatol.1995;22:829-835.
  9. Singh G, Fries JF, Williams CA, Zatarain E, Spitz P, Bloch DA. Toxicity profiles of disease modifying antirheumatic drugs in rheumatoid arthritis. J Rheumatol. 1991;18:188-194.
  10. McDougall R, SibleyJ, Haga M, Russell AS. Outcome in patients with rheumatoid arthritis receiving prednisone compared to matched controls. J Rheumatol.1994;21:1207-1213.
  11. Van Staa T, Leufkens H, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids and risk of fracture. J Bone Miner Res. 2000;15:993-1000.
  12. Wolfe F, Caplan L, Michaud K. Treatment for rheumatoid arthritis and the risk of hospitalization for pneumonia. Arth Rheum. 2006;54:628-634.
  13. Dixon WG, Suissa S, Hudson M. The association between systemic glucocorticoid therapy and the risk of infection in patients with rheumatoid arthritis: Systematic review and meta-analyses. Arthritis Res Ther. 2011;13:R139.
  14. Strangfeld A, Listing J, Herzer P, et al. Risk of Herpes Zoster in patients with rheumatoid arthritis treated with anti-TNF agents. JAMA. 2009;301:737-744.
  15. Brassard P, Lowe A-M, Bernatsky S, Kezouh A, Suissa S. Rheumatoid arthritis, its treatment and the risk of tuberculosis in Quebec, Canada. Arth Care Res. 2009;61:300-304.
  16. Myasoedova E, Matteson EL, Tallet NJ, Crowson C. Increased incidence and impact of upper and lower gastrointestinal events in patients with rheumatoid arthritis in Olmsted county, Minnesota: A longitudinal population study. J Rheumatol. 2012;39:1355-1362.
  17. Caplan L, Wolfe F, Russell AS, Michaud K. Corticosteroid use in rheumatoid arthritis: Prevalence, predictors, correlates and outcomes. J Rheumatol. 2007;34:696-705.
  18. Lacaille D, Anis AH, Guh DP, Esdaile JM. Gaps in care for rheumatoid arthritis: A population study. Arth Care Res. 2005;53:241-248.
  19. Caplan L, Russell AS, Wolfe F. Steroids for rheumatoid arthritis: The honeymoon revisited (once again). J Rheumatol. 2005;32:1862-1865.
  20. Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64:625-639.

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Filed under:ConditionsDrug UpdatesRheumatoid Arthritis Tagged with:Oral CorticosteroidsRARheumatoid arthritisSteroid

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