Rethinking the Balance of Risks and Rewards of Chronic Low-Dose Glucocorticoids in Rheumatoid Arthritis
Authors: Dana E. Orange, Bella Mehta
Journal: Annals of Internal Medicine (2020)

Editorials1 December 2020Rethinking the Balance of Risks and Rewards of Chronic Low-Dose Glucocorticoids in Rheumatoid ArthritisDana E. Orange, MD, MS and Bella Mehta, MBBS, MSDana E. Orange, MD, MSHospital for Special Surgery, New York, and Laboratory of Molecular Neuro-Oncology & Howard Hughes Medical Institute, The Rockefeller University, New York, New York (D.E.O.)Search for more papers by this author and Bella Mehta, MBBS, MSHospital for Special Surgery and Weill Cornell Medicine, New York, New York (B.M.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-6010 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Despite recent advances in the management and therapeutics of rheumatoid arthritis (RA), glucocorticoids (GCs) remain one of the most effective treatments for the rapid reduction of symptoms of the disease and are therefore still widely used. The discovery of the remarkable efficacy of GCs to treat RA-associated inflammation dates back to the 1940s (1); however, it quickly became clear that GC use was associated with significant toxicities, including infection, adrenal insufficiency, osteoporosis, gastrointestinal bleeding, diabetes mellitus, and cataracts (2). In early RA, GCs improve clinical and radiographic outcomes (3–5), and recent recommendations for RA management recommend GCs at the lowest ...References1. Hench PS, Kendall EC. The effect of a hormone of the adrenal cortex (17-hydroxy-11-dehydrocorticosterone; compound E) and of pituitary adrenocorticotropic hormone on rheumatoid arthritis. Proc Staff Meet Mayo Clin. 1949;24:181-97. [PMID: 18118071] MedlineGoogle Scholar2. Rhen T, Cidlowski JA. Antiinflammatory action of glucocorticoids—new mechanisms for old drugs. N Engl J Med. 2005;353:1711-23. [PMID: 16236742] CrossrefMedlineGoogle Scholar3. Goekoop-Ruiterman YP, de Vries-Bouwstra JK, Allaart CF, et al. Clinical and radiographic outcomes of four different treatment strategies in patients with early rheumatoid arthritis (the BeSt study): a randomized, controlled trial. Arthritis Rheum. 2005;52:3381-90. [PMID: 16258899] CrossrefMedlineGoogle Scholar4. Landewé RB, Boers M, Verhoeven AC, et al. COBRA combination therapy in patients with early rheumatoid arthritis: long-term structural benefits of a brief intervention. Arthritis Rheum. 2002;46:347-56. [PMID: 11840436] CrossrefMedlineGoogle Scholar5. Daien CI, Hua C, Combe B, et al. Non-pharmacological and pharmacological interventions in patients with early arthritis: a systematic literature review informing the 2016 update of EULAR recommendations for the management of early arthritis. RMD Open. 2017;3:e000404. [PMID: 28151539] doi:10.1136/rmdopen-2016-000404 CrossrefMedlineGoogle Scholar6. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis. 2020;79:685-699. [PMID: 31969328] doi:10.1136/annrheumdis-2019-216655 CrossrefMedlineGoogle Scholar7. George MD, Baker JF, Winthrop K, et al. Risk for serious infection with low-dose glucocorticoids in patients with rheumatoid arthritis. A cohort study. Ann Intern Med. 2020;173:870-8. doi:10.7326/M20-1594 LinkGoogle Scholar8. Rutherford AI, Subesinghe S, Hyrich KL, et al. Serious infection across biologic-treated patients with rheumatoid arthritis: results from the British Society for Rheumatology Biologics Register for Rheumatoid Arthritis. Ann Rheum Dis. 2018;77:905-910. [PMID: 29592917] doi:10.1136/annrheumdis-2017-212825 CrossrefMedlineGoogle Scholar9. Au K, Reed G, Curtis JR, et al; CORRONA Investigators. High disease activity is associated with an increased risk of infection in patients with rheumatoid arthritis. Ann Rheum Dis. 2011;70:785-91. [PMID: 21288960] doi:10.1136/ard.2010.128637 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Hospital for Special Surgery, New York, and Laboratory of Molecular Neuro-Oncology & Howard Hughes Medical Institute, The Rockefeller University, New York, New York (D.E.O.)Hospital for Special Surgery and Weill Cornell Medicine, New York, New York (B.M.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-6010.Corresponding Author: Dana E. Orange, MD, MS, Rockefeller University, 1230 York Avenue, New York, NY 10065; e-mail, [email protected]edu.Current Author Addresses: Dr. Orange: Rockefeller University, 1230 York Avenue, New York, NY 10065.Ms. Mehta: Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021.This article was published at Annals.org on 22 September 2020. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals On Call - Low-Dose Steroids and Risk for Infection Robert M. Centor and Michael D. George Metrics Cited byNanomedicines Targeting Respiratory Injuries for Pulmonary Disease Management 1 December 2020Volume 173, Issue 11Page: 933-934KeywordsBiologicsDisease modifying antirheumatic drugsEmergency departmentHealth care utilizationHospitalizationsInfectious diseasesMedicareOpioidsRheumatoid arthritisSoft tissue infections ePublished: 22 September 2020 Issue Published: 1 December 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...