Steroids in Rheumatoid Arthritis – How Much? How Long?

Rheumatoid arthritis (RA) is the most form of inflammatory arthritis and affects approximately 2 million Americans. It is a systemic potentially lethal autoimmune disease that affects not only the joints but internal organs as well.

Recent advances in the use of disease modifying anti rheumatic drugs (DMARDS) as well as biologic therapies have permitted rheumatologists to achieve remission in the majority of patients with RA.

One medication that is frequently lost in the shuffle and still remains the topic of debate in many circles is prednisone. Prednisone is a glucocorticoid, a group of medicines that have profound anti-inflammatory effects.

Because of this property, rheumatologist frequently employ prednisone as a “bridge” therapy to help with symptoms until the beneficial effects of more potent DMARDS and biologic therapies can kick in.

Also, it has been shown that this combination can also slow down the rate of x-ray progression of joint disease.

The use of prednisone also reduces the need for non-steroidal anti-inflammatory drugs (NSAIDS) which themselves carry potential side effect risks for gastrointestinal ulceration as well as increased likelihood of cardiovascular complications, such as stroke and heart attack.

On the flip side, the use of chronic low dose prednisone is not without potential problems. Even in relatively low doses such as 5 mgs a day, prednisone can increase the risk for skin thinning, cataracts, osteoporosis, and other medical problems. One author has reported that using a dose higher than 5 mgs per day can increase the risk for pneumonia.

Many rheumatologists tend to use prednisone in a dose of 7.5-10 mgs a day for 6 months as a bridge. But this certainly isn’t a universal habit. Some rheumatologists use a higher dose, others use prednisone for a much longer period of time and there are some rheumatologists who don’t use prednisone at all.

Personally, I try to keep the dose at 5 mgs per day. When the patient is stable and in remission, I also like to begin tapering the prednisone slowly. By slowly, I mean one mg a month.

Prednisone should only be given in the morning. The reason is that the body’s adrenal glands, which produce glucocorticoids have a diurnal rhythm. The make more glucocorticoid in the morning and less in the evening. By supplying prednisone in a manner that mimics the body’s biology, there is less potential for causing untoward side effects.

This article has focused only on oral prednisone. There are many other steroids that can be injected either directly into the joint or given intravenously. They will be the topic of another article.