At the 2003 meeting of the American College of Rheumatology (ACR) a debate on the advantages and disadvantages of glucocorticoids (GCs) in the treatment of early and late rheumatoid arthritis (RA) was held, with some authors putting the case for, and others the case against, such treatment (presentations now available online: http://www.rheumatology.org). Some new data emerged, and this paper summarises the arguments and the existing and new data.

HISTORY

Hench was awarded the Nobel prize in 1950 for the discovery of GCs and their effect in established RA. However, subsequently disillusionment with GCs set in, caused by the rapid appearance of unacceptable side effects of long term high dose treatment, and loss of efficacy at lower dosing. The dogma became that treatment with systemic GCs caused only temporary symptomatic relief, led to habituation with danger of ever increasing doses necessary to maintain effect, and that chronic treatment universally caused unacceptable side effects. Therefore, such treatment was often only considered as a last resort. An associated idea was that RA was in most cases a benign disease, which, although incurable, caused significant disability in only a minority of cases. The combination of these ideas caused most rheumatologists to limit treatment to traditional schemes that emphasised rest, lifestyle adjustment, non-steroidal anti-inflammatory drugs (NSAIDs), and spa treatment. In unresponsive cases antirheumatic drugs such as intramuscular gold were advised. A paradigm shift was initiated by Wilske and Healey, who argued that the pyramid should be inverted and aggressive treatment should be started early.¹ This was based on the appearance of long term outcome studies that recorded the dismal prognosis of many patients when followed up for a …