Low dose glucocorticoids in early rheumatoid arthritis

The use of glucocortioid therapy in the treatment of rheumatoid arthritis [RA] remains controversial. There has been much data accumulated over the years describing both the risks and benefits of acute and chronic glucocorticoid therapy. Initially there was significant enthusiasm for this type of therapy given the extent of the anti-inflammatory effects. However, use was then modified as chronic therapy with higher doses was associated with frequent reports of important safety concerns. More recently low dose glucocorticoid therapy (e.g. less than or equal to 5 mg prednisone per day) is being reconsidered in particular for patients with early disease. This paper will review the historical experience with higher dose therapy along with the evolving evidence of an improved benefit to risk ratio with the advent of concomitant therapies to minimize some of the more problematic adverse events associated with chronic use of even low dose glucocorticoid therapy. It is suggested that with appropriate monitoring and careful concomitant prophylactic therapy to prevent osteoporosis, adjunctive therapy using low dose glucococorticoids along with the appropriate disease modifying anti-rheumatic drug may be a reasonable treatment plan for select patients.