Panelists Discuss How and When to Safely Use Steroids in RA

Corticosteroids should be used at the lowest dose, for the shortest duration possible, and only when necessary, according to three rheumatoid arthritis (RA) experts who discussed the topic during Meet the Panel: RA.

The session is available for on-demand viewing for registered ACR Convergence participants through October 31, 2024, on the meeting website.

Rheumatologists may be tempted to use steroids in patients with very active disease as they wait for a disease-modifying antirheumatic drug (DMARD) to take effect. But Vivian Bykerk, MD, Professor of Medicine, Weill Cornell Medical College, cautioned that this bridging strategy can be counterproductive.

“We generally start steroids in patients with higher disease activity,” she said. “But studies have shown that this may delay the use of a biologic, putting the patient at risk of longer steroid use. We need steroids, but we need patients to come back and to taper them.”

Steroids may also be considered when a patient is experiencing a flare. Clifton Bingham, MD, Director, Johns Hopkins Arthritis Center, recommended querying patients on their symptoms, symptom duration, and how quickly they need their symptoms to resolve to determine whether steroids are appropriate.  

“I don’t typically give steroids to patients who are flaring,” Dr. Bingham said. “Given the fact that many flares self-resolve, the first strategy is to watch and wait or consider short courses of non-steroidal agents.”

Frequent flares may also be a sign that a patient may need to switch to a new regimen.

Liana Fraenkel, MD, MPH, Professor Adjunct, Yale School of Medicine, and lead author on the 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, addressed the ACR’s position on steroid use. The guideline recommends initiating conventional synthetic DMARDs without glucocorticoid steroids while recognizing that short-term treatment may be appropriate for some patients.   

“We wanted to change the status quo,” Dr. Fraenkel said. “The ACR does not recommend that all patients start on a glucocorticoid steroid. There are conditions when they should be used, but we should stop and consider whether we really need to start prednisone and if there are other things we can do.”

Panelists also discussed the data for the association between corticosteroid use and toxicities — specifically infections, cardiovascular disease, and osteoporosis. Several recent, large, observational datasets reveal a consistent picture: Daily dose, cumulative dose, and duration are all associated with increased toxicity.

These data may challenge what rheumatologists consider “low-dose prednisone,” said Joel Kremer, MD, Founder and President of the Corrona Research Foundation. Doses as low as 5 mg of prednisone are associated with an increased risk of serious infection and cardiovascular events, while 2.5 mg of prednisone may increase the risk of fractures.

Even if patients recover from these toxicities, they may impact their RA treatment.

“For patients who get a serious infection, it’s about what happens after,” Dr. Fraenkel said. “Patients and providers become more risk-averse. This impacts the rest of the treatment journey.”

Discussing these data is a key part of the shared decision-making that should be included in any treatment discussion.

“We have more information to share with patients when thinking about dose and the consequences of using steroids,” said Dr. Bingham. “When we discuss steroids with patients, we need to balance the suffering they are experiencing with the very real harms and concerns.”