Rheumatoid arthritis is a chronic inflammatory disease in which the body's immune system attacks and destroys healthy joint tissue. The small joints of the hands, wrists, and feet are most frequently affected, and as the disease progresses it can cause pain, swelling, deformity and disability. Larger joints and other organ systems can also become affected.
The treatment of RA involves the use of a combination of medicines: fast-acting anti-inflammatory drugs and more slow acting disease modifying drugs (DMARDS).
Prednisone, a potent anti-inflammatory steroid, is often used by rheumatologists early on to treat rheumatoid arthritis (RA). It is most often used sparingly, in low doses because of the potential side effects. High doses can contribute to heart disease, cataracts, thinning of the skin, ulcers, adrenal suppression, osteoporosis and other complications. Questions remain about whether smaller doses lead to similar problems.
Rheumatologist use prednisone as a "bridge" to suppress inflammatory symptoms between the start of therapy and when disease-modifying drugs begin to kick in. The "bridge" dose is generally 5-10 mgs. This dose is then tapered as the patient improves.
In the past, some rheumatologists have often been reluctant to prescribe prednisone because of the potential side effects. Other rheumatologists have been more aggressive in their use of prednisone (including this author) but have done so through the process of experience and use of empirical data.
Low doses of steroids can inhibit joint damage when used in the early phase of rheumatoid arthritis, according to a new review of evidence. (Kirwan JR, et al. Effects of glucocorticoids on radiological progression in rheumatoid arthritis (Review). Cochrane Database of Systematic Reviews 2007, Issue 1).
The review appeared 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 was based on 15 studies including 1,414 patients. In most of the studies, patients received low doses of glucocorticoid pills along with 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," the authors led by John Kirwan of Liverpool Women's Hospital in England say.
High-quality evidence supports combining the glucocorticoids with standard medications in the first two years after diagnosis.
Concern still exists about the potential side effects of steroid therapy, however.
The authors do add, however, that reduction of joint damage seen on X-rays may not correlate with 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 cited a 2006 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.
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.
Authors note: This review supports the stance that I and many of my colleagues have had for many years. Low dose corticosteroids are valuable and have their place in the management of RA, particularly early on. The "window" for protecting joints against almost certain deterioration is early and small.
Patients recently diagnosed with rheumatoid arthritis should see a rheumatologist as soon as possible. Early and aggressive treatment can prevent severe joint damage and disability for most people. The use of newer biologic therapies has allowed rheumatologists to get many people with rheumatoid arthritis into full remission.
Note: This story has been adapted from a news release issued by Center for the Advancement of Health.
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