Steroids in rheumatoid arthritis

Steroid treatment is widely used in rheumatoid arthritis. It is used as an adjunct to anti-inflammatory drugs and disease modifying anti-rheumatic drugs (DMARDs). It usually helps improve symptoms rapidly during an acute flare or whilst a DMARD has time to take effect (a 'bridging treatment'). In the elderly it is often also used in low dose to help maintain remission.

• steroids may be administered orally, intra-muscularly and intra-articularly.
• for 'bridging treatment' (specialist advice required), intra-articular corticosteroids may be considered for localised disease, and systemic corticosteroids for more generalised disease
  • for a monoarticular flare, if appropriate, an intra-articular corticosteroid injection will often give rapid relief of symptoms - intra-articular corticosteroid injections should always be administered by an appropriately skilled person
  • systemic corticosteroids can be considered for a monoarticular flare if intra-articular injection is not possible, or for a polyarticular flare
• concern however continues about the potential side-effects of corticosteroid use, including Cushing's syndrome, osteoporosis, hypertension etc.
  • with respect to risk of osteoporosis
    • in patients either committed to long-term oral corticosteroids or who have been exposed to long-term oral corticosteroid treatment for three months or more, osteoporosis prophylaxis is recommended if patients are aged 65 years or over, or aged under 65 years with a history of a previous fragility fracture. In the absence of a prior fragility fracture in those aged under 65 years, a bone mineral density (BMD) test is recommended and osteoporosis prophylaxis should be considered where the T-score is -1.5 standard deviation (SD) or lower
    • increased osteoporosis risk is seen even at daily doses of prednisolone less than 7.5mg
    • note also that RA increases the risk of osteoporosis even in the absence of corticosteroid therapy

NICE suggest that:

• offer short-term treatment with glucocorticoids for managing flares in adults with recent-onset or established disease to rapidly decrease inflammation
• in adults with established RA, only continue long-term treatment with glucocorticoids when:
  • the long-term complications of glucocorticoid therapy have been fully discussed, and
  • all other treatment options (including biological and targeted synthetic DMARDs) have been offered

Reference:

1. MeReC Bulletin 2007;17(5):1-8
2. NICE (July 2018). Rheumatoid arthritis- The management of rheumatoid arthritis in adults