Some patients with rheumatoid arthritis (RA) might be treated effectively with doses of prednisone below 5 mg daily, according to new data.
Numerous studies have demonstrated the efficacy and relative safety of low-dose prednisone, which is commonly used to treat RA patients over the long term. Guidelines, however, recommend limited glucocorticoid use in rheumatoid arthritis in favour of disease modifying anti-rheumatic drugs (DMARDs).
Dr Theodore Pincus from New York University School of Medicine in New York City and colleagues analysed the course and outcome of prednisone treatment from 1980-2004 in 308 RA patients, including 75 monitored over four to eight years.
As reported November 30 online in Arthritis Care & Research, the mean initial prednisone dose declined over the years from 10.3 mg/day in 1980-1984 to 3.6 mg/day in 2000-2004.
How the study was done
Prednisone was usually prescribed at the first visit, and a DMARD (primarily gold salts prior to 1985 and methotrexate thereafter) was initiated in most patients by the second visit. The proportion of patients treated with methotrexate increased progressively from 10% in 1980-1984 to 51% in 1990-1994 to 78% in 2000-2004.
Mean scores on the multidimensional health assessment questionnaire (MDHAQ) used by the authors improved from first to last visit, other than identical scores for physical function (which tended to rise with ageing) after eight years.
Weight remained similar to baseline in patients monitored for more than a year. Among patients monitored for more than eight years, 12% developed hypertension, 11% developed cataracts, and 7% developed diabetes. However, among those taking low-dose prednisone, fewer than 7% developed hypertension, fewer than 4% developed cataracts, and fewer than 3% developed diabetes.
Further research needed
"The data suggest that many patients with rheumatoid arthritis might be treated effectively with initial and long-term prednisone <5 mg/day, although further research and observational data are needed to establish effectiveness and safety," the researchers conclude.
Dr Pincus did not respond to a request for comments about this study. But Dr J. W. G Jacobs from University Medical Center Utrecht, Utrecht, The Netherlands, who wasn't involved in the study, agreed that the findings are preliminary. "Very low doses might have a beneficial symptomatic effect, but this requires proof," Dr Jacobs told Reuters Health by email.
"In time, prednisone dosages decreased, but methotrexate dosages increased, so methotrexate might have enabled decreasing the doses of prednisone," Dr Jacobs said. "And-as for each observational study-how do I know if prednisone really had any effect beyond that of placebo? If so, would the increase of methotrexate not have yielded the same effect?"
For these reasons, Dr. Jacobs said, the new data should not alter the current management of patients with rheumatoid arthritis.
(EurekAlert, December 2012)
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