Low-dose steroids reduce joint damage from rheumatoid arthritis

High-quality evidence supports combining the pills with standard medications in the first two years after diagnosis. “Such treatment should be made readily available to patients,” say review authors led by John Kirwan of Liverpool Women's Hospital in England.

Concern exists about the side effects of steroid therapy, however. High doses can contribute to heart disease, osteoporosis and other complications. Questions remain about whether smaller doses lead to similar problems.

Rheumatoid arthritis is a chronic disease in which the body's immune system attacks and destroys healthy joint tissue. The hands and feet are frequently affected, and as the disease progresses it can cause pain, swelling, deformity and disability.

The steroids studied in the review are known as glucocorticoids and include the well-known anti-inflammatory prednisone. This medication is often prescribed in the first few months after diagnosis to relieve the discomfort of RA until slower-acting drugs begin protecting the joints.

Until now, concerns about side effects caused most rheumatologists to “put people on the lowest possible dose of steroids and get them off it as soon as possible,” said Scott Zashin, M.D., of the University of Texas Southwestern Medical Center. “Now, we have to give steroids a little more respect.”

The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

The systematic review is based on 15 studies including 1,414 patients. In most of the studies, patients received low doses of glucocorticoid pills along with so-called disease-modifying drugs for one to two years. Periodic X-rays revealed the extent of joint erosion and other signs of damage.

All studies except one showed reduced progression of joint damage in patients taking glucocorticoids. When reviewers used statistical methods to focus on only the highest-quality data, the benefits remained statistically significant.

“Even in the most conservative estimate, the evidence that glucocorticoids given in addition to standard therapy can substantially reduce the rate of erosion progression in rheumatoid arthritis is convincing,” they say.

The authors say, however, that minimization of joint damage seen on X-rays may not equate to noticeable improvements for patients: “It does not necessarily follow that patients will gain long-term functional benefit.” However, two related studies, including one by Kirwan, suggest “an important link” between the two.

Because of the known health risks associated with intensive steroid use, concern persists regarding long-term use at any level. The authors cite a 2006 systematic review covering the adverse effects of low-dose glucocorticoids, which concluded that “few of the commonly held beliefs about their incidence, prevalence and impact are supported by clear scientific evidence.”

Moreover, safety data from recent randomized controlled clinical trials of low-dose steroids for RA suggest that negative side effects are “modest” and similar to those of sham treatments, say Kirwan and colleagues. Additionally, the most immediate concern — reduced bone mineral density — can now be readily treated.

Nevertheless, potential adverse reactions to glucocorticoid therapy merit further research, say the authors, as does usefulness of steroid treatment for patients who have had rheumatoid arthritis for 3 years or more.

Zashin urges patients recently diagnosed with rheumatoid arthritis to see a rheumatologist without delay. Early and aggressive treatment can prevent severe joint damage and disability for most people, he says.

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