We Still Don’t Know How to Taper Glucocorticoids in Rheumatoid Arthritis, and We Can Do Better

Rheumatologists, internists, residents, and fellows frequently ask, “How do you taper glucocorticoids in rheumatoid arthritis?” Despite controlling symptoms of rheumatoid arthritis (RA)1 and slowing progression of radiological joint damage in early RA2, low-dose glucocorticoids (GC) are associated with a plethora of chronic adverse effects, including diabetes mellitus, hypertension, atherosclerosis, weight gain, osteoporosis, skin fragility, Cushingoid appearance, and myopathy, and are also associated with increased risk of infection, cardiovascular events, depression, cataracts, and skin atrophy3,4. To prevent or minimize these effects, GC tapering to the lowest dose necessary to maintain control of disease activity is recommended5. However, strategies to taper GC vary, and are mostly described based on expert opinion. No clinical trials have directly examined, much less compared, different GC tapering regimens in RA5. Withdrawal of GC may also precipitate adverse events, including flare, adrenal insufficiency, and GC withdrawal syndrome6. To attempt to answer this frequent question, we performed a systematic literature review to assess the influence of tapering regimens on successful GC withdrawal, as well as clinical outcomes. We searched PubMed and Cochrane Central to identify publications from January 1972 to February 2011 (detailed search strategy available on request). Search terms comprised 4 blocks that were combined with Cochrane hedge, “methodological filter for clinical trials.” The first block addressed disease (RA in adults); the second and third, intervention (GC/related terms AND tapering); and the fourth, outcome (withdrawal/dose reduction, effect on disease activity). We double-extracted all titles and abstracts according to the following: inclusion criteria: (a) adult patients with RA; (b) studies in which GC and related terms (e.g., corticosteroids, prednisone, prednisolone, etc.) were used; and exclusion criteria: (a) case report or case series with < 20 patients; (b) editorials, review articles, letters, opinions, etc. Two of … Address correspondence to Dr. D.E. Furst, Division of Rheumatology, Department of Medicine, University of California, Los Angeles, 32-59 Rehabilitation Center, 1000 Veteran Avenue, Los Angeles, CA 90095, USA. E-mail: defurst{at}mednet.ucla.edu