Low-Dose Corticosteroid Use Safe in Rheumatoid Arthritis

Abstract & Commentary

By Joseph E. Scherger, MD, MPH, Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study.

Synopsis: A systematic review of published literature by a working group of European and American rheumatologists and endocrinologists showed that while the evidence is limited, the use of 10 mg or less of prednisone daily for more than 2 years in patients with rheumatoid arthritis was without serious side effects such as osteoporosis, fractures, peptic ulcer, high blood pressure, or heart disease. Modest increases in fasting blood glucose and body weight were seen along with skin atrophy and bruising.

Source: Da Silva JA, et al. Safety of low dose glucocorticoid treatment in rheumatoid arthritis: published evidence and prospective trial data. Ann Rheum Dis. 2006;65:285-293.

An impressive team of authors from seven European countries and the United States conducted a systematic review of the scientific literature on the risks and side effects of low-dose corticosteroids in the treatment of chronic rheumatoid arthritis. Given how long these drugs have been available, the quality of the studies was variable, and rigorous studies were scant. Four randomized controlled trials were found which did not show any increase in osteoporotic fractures when the equivalent of 10 mg of prednisone or less was used for 1-2 years or longer. Osteonecrosis of the femoral head was not seen with low-dose use. Increased glucose intolerance was seen with an average increase in fasting blood sugar of 14 mg/dL. In one case-control study, an almost 2-fold increase in the likelihood of treatment for hyperglycemia was found with long-term low-dose use. Body weight in the 4 controlled trials showed an increase of 4 to 8% over 2 years. There was no increase in blood pressure, cardiovascular disease or peptic ulcer disease. Skin atrophy and bruising occurred in more than 5% of patients taking at least 5 mg of prednisone for 1 year.

The authors conclude that most of the commonly held beliefs about the risks of corticosteroids used long term were not found with low-dose use. They opine that the adverse effects associated with these drugs are modest, and often not statistically different from those of placebo.

Commentary

Many of the current disease-modifying treatments for rheumatoid arthritis and other rheumatologic diseases are expensive and have concerns for toxicities. When cortisone came out many years ago, it was considered a wonder drug for arthritis. Then the adverse effects came in squelching its long-term use. However, the ability of prednisone to rapidly improve a flair of inflammatory arthritis is well known and commonly used. Low-dose prednisone can be highly effective, affordable and practical in controlling chronic inflammation, and is commonly used for polymyalgia rheumatica and temporal arteritis. Often patients with rheumatoid arthritis ask for it as a practical way to become comfortable with this often miserable disease. This careful international review of the scientific literature provides support for the long-term use of low-dose corticosteroid therapy.

This study should not result in a boon to long-term use of low-dose prednisone to treat rheumatoid arthritis and other rheumatologic diseases. For most of our patients, we are not talking about 2 years, but 10-20 years or longer. We have all seen the skin changes of decades of steroid use, even with low doses, and the cosmetic impact along with reduced quality of life (no handshakes, hugging, and even social isolation). This study is very reassuring with respect to bones, stomach, and the heart. Sometimes being able to give 5-10 mg of prednisone over a long period brings great relief, especially when the newer disease modifying agents are simply not available or practical. Treating rheumatoid arthritis and related conditions requires the art of medicine, individualizing therapies for helping patients. These authors have done a great service to us in re-opening a practical and effective line of therapy.