Background Traditional approaches to corticosteroids in rheumatoid arthritis (RA) have been to avoid and/or discontinue their use if at all possible. However, corticosteroids are associated with improved patient well being, and are recognised to be disease modifying in RA.
Objectives To analyse results in use of long-term low-dose prednisone in 102 consecutive patients with RA seen in a weekly academic rheumatology clinic from 1982 to 1999, with a mean starting dose of 4.3 mg/day, according to scores for functional capacity and pain on a multidimensional health assessment questionnaire (MDHAQ), and possible toxicities of corticosteroids.
Methods Each patient completed a multidimensional health assessment questionnaire (MDHAQ) at each visit to assess functional disability, pain and drugs taken. Drugs taken, changes in scores for functional disability pain, and possible corticosteroid toxicities were analysed using descriptive statistics.
Results Among the 102 consecutive patients, 96 (94%) were taking low dose prednisone over a median of 6.1 consecutive years. All but 6 patients were also taking disease-modifying antirheumatic drugs, including 86% taking methotrexate. The mean starting dose of prednisone in 74 patients whose prednisone was begun at this rheumatology clinic was 4.3 mg (median dose 5 mg/day), compared to 13.1 mg/day (median dose 10 mg/day) in 22 patients whose prednisone was begun at other clinical sites. At the most recent visit, 53 patients (52% of all patients and 55% of corticosteroid users) were taking < 5 mg/day; 48 of these patients had their prednisone begun at this clinic. By contrast, 4 patients were taking >10 mg/day, all of whom had prednisone begun at another site. Median functional disability scores were 0.5 (range 0‑3), and 3.4 for pain (range 0‑10); scores for functional disability and pain tended to be higher in patients who took higher doses of prednisone, and the highest scores were seen in the 4 patients who took >10 mg/day. Compared to baseline 0.1‑18 years earlier, 40% of patients had MDHAQ functional disability scores indicating improvement by >0.25 units, 39% were unchanged by <0.25 units, and 21% had progression of functional disability by 0.25 units, results considerably different from reports published in the 1980s. In analyses of possible corticosteroid toxicities, 32% of patients had hypertension, 4% had diabetes mellitus, and 20% had cataracts, percentages that are similar to those found in published reports of patients with RA.
Conclusion Long-term low-dose prednisone with a starting and maintenance dose of <5 mg/day appears to be a safe therapy, in contrast to high-dose prednisone, with long-term efficacy and low toxicities. Further studies are needed lead to more accurate characterise of the risks and benefits of long-term low dose corticosteroid therapy in RA.
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