Low-dose steroids are neither safe nor effective for long-term treatment of rheumatoid arthritis

September 25, 2002

Low-dose steroids are neither safe nor effective for long-term treatment of

rheumatoid arthritis

Doctors should abandon the use of low-dose glucocorticoids such as

prednisone as an antiquated approach to the treatment of rheumatoid

arthritis (RA) in favor of more targeted and safer RA treatments, recommends

G. Saag, M.D., M.Sc., in a recent commentary. He contends that

long-term low-dose glucocorticoids, a type of steroid, simply do not work

(their antiinflammatory benefits decline considerably after the first year),

and they can cause undue adverse effects and toxicity. High on the list of

problems is the dramatic bone loss and resulting fracture risk from

prolonged glucocorticoid use. Yet few RA patients are being evaluated and

treated for this potential complication.

One study estimated that more than half of glucocorticoid users develop bone

loss leading to fracture. Other studies have suggested a mean first-year

loss of bone of up to 15 percent at the dose range of 10 mg per day or less

of prednisone and up to a loss of 3 percent per year in subsequent years.

Another study found that 34 percent of women on a mean dose of prednisone of

8.6 mg per day had suffered a fracture within 5 years of followup.

Cataract is another well-described complication of prolonged glucocorticoid

use. Cataract may develop even when inhaled glucocorticoids are used. In

addition, increased intraocular pressure may develop in these patients,

increasing the risk of glaucoma.

Long-term use of low-dose glucocorticoids also may lead to development of

premature atherosclerosis. One study found a three-fold increase in

atherosclerosis in RA patients treated with glucocorticoids compared with

nonsteroid-treated patients. Biologic response-modifying drugs are now

available to treat RA, such as methotrexate, leflunomide, etanercept, and

infliximab. When the serious problems associated with glucocorticoids are

adequately explained, patients' perceptions of and preference for their use

may change markedly, says Dr. Saag. His work at the Center for Education and

Research on Therapeutics of Musculoskeletal Disorders, University of Alabama

at Birmingham, is supported in part by the Agency for Healthcare Research

and Quality (HS10389).

More details are in " Resolved: Low-dose glucocorticoids are neither safe nor

effective for the long-term treatment of rheumatoid arthritis, " by Dr. Saag,

in the October 2001 Arthritis Care & Research 45, pp. 468-471.

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