title: Benefits and risks of low-dose glucocorticoid treatment in the patient with rheumatoid arthritis.
abstract: Glucocorticosteroids (GCs) have been employed extensively for the treatment of rheumatoid arthritis (RA) and other autoimmune and systemic inflammatory disorders. Their use is supported by extensive literature and their utility is reflected in their incorporation into current treatment guidelines for RA and other conditions. Nevertheless, there is still some concern regarding the long-term use of GCs because of their potential for clinically important adverse events, particularly with an extended duration of treatment and the use of high doses. This article systematically reviews the efficacy for radiological and clinical outcomes for low-dose GCs (defined as ≤10 mg/day prednisone equivalent) in the treatment of RA. Results reviewed indicated that low-dose GCs, usually administered in combination with synthetic DMARDs, most often MTX, significantly improve structural outcomes and decrease symptom severity in patients with RA. Safety data indicate that GC-associated adverse events are dose related, but still occur in patients receiving low doses of these agents. Concerns about side effects associated with GCs have prompted the development of new strategies aimed at improving safety without compromising efficacy. These include altering the structure of existing GCs and the development of delayed-release GC formulations so that drug delivery is timed to match greatest symptom severity. Optimal use of low-dose GCs has the potential to improve long-term outcomes for patients with RA.
authors.affiliation: Department of Medicine, University of California, San Diego, La Jolla, CA and Department of Rheumatology, Duke University Medical Center, Durham, NC, USA. akavanaugh@ucsd.edu.
authors.forename: Arthur
authors.initials: A
authors.lastname: Kavanaugh
authors.affiliation: Department of Medicine, University of California, San Diego, La Jolla, CA and Department of Rheumatology, Duke University Medical Center, Durham, NC, USA.
authors.forename: Alvin F
authors.initials: AF
authors.lastname: Wells
mesh_terms: D001172:Arthritis, Rheumatoid / Q000000981:diagnostic imaging / Q000188:drug therapy*; D018450:Disease Progression; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D011859:Radiography; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D005938:Glucocorticoids
keywords: benefit–risk; disease modifying; glucocorticoids; prednisone; rheumatoid arthritis; treatment strategies
references.citation: Ann Rheum Dis. 2010 Jul;69(7):1275-80
references.pmid: 20542963
references.citation: Lancet. 2009 May 30;373(9678):1905-17
references.pmid: 19482216
references.citation: Pharmazie. 1999 Jan;54(1):58-61
references.pmid: 9987798
references.citation: Arthritis Rheum. 2008 Feb;58(2 Suppl):S126-35
references.pmid: 18240203
references.citation: J Rheumatol. 2007 Sep;34(9):1810-6
references.pmid: 17696277
references.citation: Ann Rheum Dis. 2004 Jun;63(6):688-95
references.pmid: 15140776
references.citation: Ann Rheum Dis. 2011 Jun;70(6):1039-46
references.pmid: 21415052
references.citation: Ann N Y Acad Sci. 2010 Apr;1193:123-6
references.pmid: 20398017
references.citation: Ann Rheum Dis. 2007 Jul;66(7):974-6
references.pmid: 17392349
references.citation: Ann Rheum Dis. 2004 Jul;63(7):797-803
references.pmid: 15194574
references.citation: Ann Rheum Dis. 2010 Jul;69(7):1342-5
references.pmid: 20472597
references.citation: J Neurosci. 2008 Mar 26;28(13):3474-8
references.pmid: 18367613
references.citation: J Rheumatol. 2008 Jun;35(6):979-85
references.pmid: 18412314
references.citation: Arthritis Rheum. 2009 May;60(5):1222-31
references.pmid: 19404945
references.citation: Arthritis Rheum. 2003 Jul;48(7):2059-66
references.pmid: 12847701
references.citation: Arthritis Rheum. 2005 Nov;52(11):3360-70
references.pmid: 16255010
references.citation: Mol Cell Endocrinol. 2007 Sep 15;275(1-2):71-8
references.pmid: 17630118
references.citation: Rheumatology (Oxford). 2000 Sep;39(9):1031-6
references.pmid: 10986311
references.citation: Autoimmun Rev. 2005 Nov;4(8):497-502
references.pmid: 16214085
references.citation: J Pediatr. 1997 Jan;130(1):13-6
references.pmid: 9003845
references.citation: J Rheumatol. 2010 Oct;37(10):2025-31
references.pmid: 20682671
references.citation: Ann Rheum Dis. 2009 Jun;68(6):914-21
references.pmid: 18662933
references.citation: Ann Intern Med. 2007 Mar 20;146(6):406-15
references.pmid: 17371885
references.citation: Clin Exp Rheumatol. 2011 Sep-Oct;29(5 Suppl 68):S42-5
references.pmid: 22018182
references.citation: Z Rheumatol. 2000;59 Suppl 2:II/90-6
references.pmid: 11155812
references.citation: J Bone Miner Res. 2012 Nov;27(11):2238-41
references.pmid: 23074079
references.citation: Ann Rheum Dis. 1976 Feb;35(1):73-76
references.pmid: 1275584
references.citation: Rheumatology (Oxford). 2012 Jul;51 Suppl 5:v48-54
references.pmid: 22718927
references.citation: Nat Rev Rheumatol. 2010 Dec;6(12):693-702
references.pmid: 21119718
references.citation: Ann Rheum Dis. 2006 Mar;65(3):285-93
references.pmid: 16107513
references.citation: Scand J Rheumatol Suppl. 2011;125:28-39
references.pmid: 21529308
references.citation: Ann Rheum Dis. 2009 Jul;68(7):1119-24
references.pmid: 18684744
references.citation: Arthritis Res Ther. 2008;10(6):R128
references.pmid: 18986531
references.citation: N Engl J Med. 1995 Jul 20;333(3):142-6
references.pmid: 7791815
references.citation: Neuroimmunomodulation. 2008;15(1):19-28
references.pmid: 18667796
references.citation: Rheumatol Rehabil. 1978 Feb;17(1):8-13
references.pmid: 734314
references.citation: Ann Intern Med. 1996 Dec 15;125(12):961-8
references.pmid: 8967706
references.citation: J Rheumatol. 2012 Aug;39(8):1559-82
references.pmid: 21921096
references.citation: J Postgrad Med. 2009 Oct-Dec;55(4):296-300
references.pmid: 20083885
references.citation: Br J Rheumatol. 1995 Apr;34(4):347-51
references.pmid: 7788149
references.citation: Curr Opin Rheumatol. 1995 May;7(3):183-90
references.pmid: 7612409
references.citation: Cochrane Database Syst Rev. 2007 Jan 24;(1):CD006356
references.pmid: 17253590
references.citation: Br J Dermatol. 2007 Jul;157(1):142-8
references.pmid: 17501951
references.citation: Ann Intern Med. 2012 Mar 6;156(5):329-39
references.pmid: 22393128
references.citation: J Rheumatol. 2000 Jul;27(7):1632-7
references.pmid: 10914843
references.citation: Ann Rheum Dis. 2011 Nov;70(11):1986-90
references.pmid: 21875873
references.citation: Drugs. 1995 Aug;50(2):317-33
references.pmid: 8521761
references.citation: Arthritis Res Ther. 2010;12(5):R170
references.pmid: 20836843
references.citation: Ann Intern Med. 2002 Jan 1;136(1):1-12
references.pmid: 11777359
references.citation: Ann N Y Acad Sci. 2010 Apr;1193:139-45
references.pmid: 20398020
references.citation: Pharmazie. 1997 Jul;52(7):491-4
references.pmid: 9266587
references.citation: Arthritis Rheum. 2004 Jul;50(7):2072-81
references.pmid: 15248204
references.citation: Br J Rheumatol. 1998 Sep;37(9):930-6
references.pmid: 9783756
references.citation: Ann Rheum Dis. 2001 Mar;60(3):214-7
references.pmid: 11171680
references.citation: Expert Rev Clin Immunol. 2012 Feb;8(2):123-33
references.pmid: 22288450
references.citation: Clin Exp Rheumatol. 2003 Mar-Apr;21(2):155-60
references.pmid: 12747268
references.citation: Arthritis Rheum. 2002 Feb;46(2):347-56
references.pmid: 11840436
references.citation: J Rheumatol. 1995 Sep;22(9):1660-2
references.pmid: 8523341
references.citation: Arthritis Rheum. 2012 Dec;64(12):4029-39
references.pmid: 22886616
references.citation: Lancet. 1997 Aug 2;350(9074):309-18
references.pmid: 9251634
references.citation: Ann Rheum Dis. 2013 Feb;72(2):204-10
references.pmid: 22562974
references.citation: Arthritis Rheum. 2006 Jun 15;55(3):420-6
references.pmid: 16739208
references.citation: Arthritis Rheum. 2005 Nov;52(11):3381-90
references.pmid: 16258899
references.citation: Arthritis Res Ther. 2010;12(4):R147
references.pmid: 20642832
references.citation: Ann Rheum Dis. 2009 Apr;68(4):508-13
references.pmid: 18420939
references.citation: Lancet. 2008 Jan 19;371(9608):205-14
references.pmid: 18207016
references.citation: Arthritis Rheum. 2005 Nov;52(11):3371-80
references.pmid: 16255011
references.citation: Ann Rheum Dis. 2010 Jun;69(6):964-75
references.pmid: 20444750
references.citation: Arthritis Rheum. 2004 Apr 15;51(2):233-8
references.pmid: 15077265
references.citation: Rheumatology (Oxford). 2012 Jun;51 Suppl 4:iv27-33
references.pmid: 22685273
references.citation: Ann Rheum Dis. 2010 May;69(5):807-12
references.pmid: 19451137
references.citation: J Rheumatol. 1997 Aug;24(8):1489-94
references.pmid: 9263140
references.citation: Ann Rheum Dis. 2008 May;67(5):656-63
references.pmid: 17768173
references.citation: Arthritis Res Ther. 2012 May 14;14(3):R112
references.pmid: 22584017
references.citation: Ann Rheum Dis. 2010 Jun;69(6):1010-4
references.pmid: 20448288
references.citation: Ann Rheum Dis. 1999 Nov;58(11):713-8
references.pmid: 10531077