Are Long-Term Very Low Doses of Prednisone for Patients with Rheumatoid Arthritis as Helpful as High Doses Are Harmful?

Editorials1 January 2002Are Long-Term Very Low Doses of Prednisone for Patients with Rheumatoid Arthritis as Helpful as High Doses Are Harmful?Theodore Pincus, MD, Tuulikki Sokka, MD, PhD, and C. Michael Stein, MDTheodore Pincus, MDVanderbilt University Medical CenterNashville, TN 37232, Tuulikki Sokka, MD, PhDVanderbilt University Medical CenterNashville, TN 37232, and C. Michael Stein, MDVanderbilt University Medical CenterNashville, TN 37232Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-136-1-200201010-00013 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Treatment of rheumatoid arthritis with corticosteroids has evoked controversy for half a century. Extremely successful initial clinical results (1) led to the awarding of the 1950 Nobel Prize in Medicine to Kendall, Reichstein, and Hench. Some early clinical trials indicated that corticosteroids had "disease-modifying" properties in retarding radiographic progression (2). However, it was soon recognized that severe toxicities associated with the long-term pharmacologic doses of prednisone used at that time (20 to 40 mg) almost invariably outweighed any benefits (3). By the late 1950s, clinicians were taught that while occasional corticosteroids might be needed for acute life-threatening rheumatoid vasculitis or ...References1. Hench PS, Kendall EC, Slocumb CH, Polley HF. The effect of a hormone of the adrenal cortex (17-hydroxy-11-dehydrocorticosterone; compound E) and of the pituitary adrenocorticotropic hormone on rheumatoid arthritis. Proc Staff Meet Mayo Clin. 1949;24:181. MedlineGoogle Scholar2. . A comparison of cortisone and aspirin in the treatment of early cases of rheumatoid arthritis. Joint Committee of the Medical Research Council and Nuffield Foundation. Br Med J. 1954;29:1223-7. Google Scholar3. Bollet AJ, Black R, Bunim JJ. Major undesirable side-effects resulting from prednisolone and prednisone. JAMA. 1955;158:459-63. CrossrefMedlineGoogle Scholar4. Scott DL, Grindulis KA, Struthers GR, Coulton BL, Popert AJ, Bacon PA. Progression of radiological changes in rheumatoid arthritis. Ann Rheum Dis. 1984;43:8-17. [PMID: 6696524] CrossrefMedlineGoogle Scholar5. Pincus T, Callahan LF, Sale WG, Brooks AL, Payne LE, Vaughn WK. Severe functional declines, work disability, and increased mortality in seventy-five rheumatoid arthritis patients studied over nine years. Arthritis Rheum. 1984;27:864-72. [PMID: 6431998] CrossrefMedlineGoogle Scholar6. Harris ED, Emkey RD, Nichols JE, Newberg A. Low dose prednisone therapy in rheumatoid arthritis: a double blind study. J Rheumatol. 1983;10:713-21. [PMID: 6358491] MedlineGoogle Scholar7. Kirwan JR. The effect of glucocorticoids on joint destruction in rheumatoid arthritis. The Arthritis and Rheumatism Council Low-Dose Glucocorticoid Study Group. N Engl J Med. 1995;333:142-6. [PMID: 7791815] CrossrefMedlineGoogle Scholar8. Boers M, Verhoeven AC, Markusse HM, van de Laar MA, Westhovens R, van Denderen JC, et al . Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis. Lancet. 1997;350:309-18. [PMID: 9251634] CrossrefMedlineGoogle Scholar9. Möttönen T, Hannonen P, Leirisalo-Repo M, Nissilä M, Kautiainen H, Korpela M, et al . Comparison of combination therapy with single-drug therapy in early rheumatoid arthritis: a randomised trial. FIN-RACo trial group. Lancet. 1999;353:1568-73. [PMID: 10334255] CrossrefMedlineGoogle Scholar10. Pincus T, Brooks RH, Callahan LF. Prediction of long-term mortality in patients with rheumatoid arthritis according to simple questionnaire and joint count measures. Ann Intern Med. 1994;120:26-34. [PMID: 8250453] LinkGoogle Scholar11. Wolfe F, Mitchell DM, Sibley JT, Fries JF, Bloch DA, Williams CA, et al . The mortality of rheumatoid arthritis. Arthritis Rheum. 1994;37:481-94. [PMID: 8147925] CrossrefMedlineGoogle Scholar12. Laan RF, van Riel PL, van de Putte LB, van Erning LJ, van't Hof MA, Lemmens JA. Low-dose prednisone induces rapid reversible axial bone loss in patients with rheumatoid arthritis. A randomized, controlled study. Ann Intern Med. 1993;119:963-8. [PMID: 8105737] LinkGoogle Scholar13. Pincus T, Marcum SB, Callahan LF. Longterm drug therapy for rheumatoid arthritis in seven rheumatology private practices: II. Second line drugs and prednisone. J Rheumatol. 1992;19:1885-94. [PMID: 1294735] MedlineGoogle Scholar14. van Everdingen AA, Jacobs JW, Siewertsz van Reesema DR, Bijlsma JW. Low-dose prednisone therapy for patients with early active rheumatoid arthritis: clinical efficacy, disease-modifying properties, and side effects. A randomized, double-blind, placebo-controlled clinical trial. Ann Intern Med. 2002;136:1-12. LinkGoogle Scholar15. Stein CM, Pincus T. Placebo-controlled studies in rheumatoid arthritis: ethical issues. Lancet. 1999;353:400-3. [PMID: 9950461] CrossrefMedlineGoogle Scholar16. Pincus T, O'Dell JR, Kremer JM. Combination therapy with multiple disease-modifying antirheumatic drugs in rheumatoid arthritis: a preventive strategy. Ann Intern Med. 1999;131:768-74. [PMID: 10577301] LinkGoogle Scholar17. Weisman MH. Should steroids be used in the management of rheumatoid arthritis? Rheum Dis Clin North Am. 1993;19:189-99. [PMID: 8356253] CrossrefMedlineGoogle Scholar18. Saag KG, Criswell LA, Sems KM, Nettleman MD, Kolluri S. Low-dose corticosteroids in rheumatoid arthritis. A meta-analysis of their moderate-term effectiveness. Arthritis Rheum. 1996;39:1818-25. [PMID: 8912503] CrossrefMedlineGoogle Scholar19. Sternberg EM, Chrousos GP, Wilder RL, Gold PW. The stress response and the regulation of inflammatory disease. Ann Intern Med. 1992;117:854-66. [PMID: 1416562] LinkGoogle Scholar20. Ramos-Remus C, Sibley J, Russell AS. Steroids in rheumatoid arthritis: the honeymoon revisited. [Editorial]. J Rheumatol. 1992;19:667-70. [PMID: 1613692] MedlineGoogle Scholar21. Pincus T, Stein CM. Why randomized, controlled clinical trials do not depict accurately long-term outcomes in rheumatoid arthritis: some explanations and suggestions for future studies. Clin Exp Rheumatol. 1997;15 17 S27-38. [PMID: 9266130] MedlineGoogle Scholar22. Pincus T, Callahan LF. Taking mortality in rheumatoid arthritis seriously-predictive markers, socioeconomic status and comorbidity. J Rheumatol. 1986;13:841-5. [PMID: 3820193] MedlineGoogle Scholar Author, Article, and Disclosure InformationAuthors: Theodore Pincus, MD; Tuulikki Sokka, MD, PhD; C. Michael Stein, MDAffiliations: Vanderbilt University Medical CenterNashville, TN 37232Acknowledgment: The authors thank John P. Bilezikian, Stanley B. Cohen, Doyt L. Conn, Harris Dienstfrey, Max I. Hamburger, Roger M. Reynolds, Anthony S. Russell, Kenneth G. Saag, Arthur L. Weaver, Michael H. Weisman, and Frederick Wolfe for critical comments.Corresponding Author: Theodore Pincus, MD, Vanderbilt University Medical Center, 203 Oxford House, Nashville, TN 37232; e-mail, theodore.pincus@vanderbilt.edu.Current Author Addresses: Drs. Pincus and Sokka: Vanderbilt University Medical Center, 203 Oxford House, Nashville, TN 37232.Dr. Stein: Vanderbilt University Medical Center, Nashville, TN 37232. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoLow-Dose Prednisone Therapy for Patients with Early Active Rheumatoid Arthritis: Clinical Efficacy, Disease-Modifying Properties, and Side Effects: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial Amalia A. van Everdingen , Johannes W.G. Jacobs , Dirk R. Siewertsz van Reesema , and Johannes W.J. 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Allergic Rhinitis and its Impact on AsthmaDevelopment and Implementation of a Tobacco Cessation Training Program for Students in the Health ProfessionsReplyDrug Record Discrepancies in an Outpatient Electronic Medical Record: Frequency, Type, and Potential Impact on Patient Care at a Hemodialysis CenterCortisontherapie heuteDevelopments in Rheumatology-2002 1 January 2002Volume 136, Issue 1Page: 76-78KeywordsAdverse eventsClinical trialsCorticosteroid therapyDrug therapyDrugsHodgkin lymphomaHypertensionPathogensRheumatoid arthritisWine ePublished: 1 January 2002 Issue Published: 1 January 2002 Copyright & PermissionsCopyright © 2002 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...