Systemic corticosteroids for management of rheumatoid arthritis
Systemic corticosteroids have both anti-inflammatory and disease-modifying effects in the treatment of RA. They are often used to achieve rapid symptom control, because of their rapid onset of action. Specialists may prescribe systemic corticosteroids at presentation, during a flare (ie increase in disease activity) or while awaiting a response to DMARD therapy (which often takes between 6 to 12 weeks). Systemic corticosteroids should always be used at the lowest possible dose for the shortest possible duration.
Advice about short-term use of systemic corticosteroids for treating flare in RA is available from An Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis: Short-term use of glucocorticoids for treating flare in RA1. If the patient is already on DMARD therapy and has a flare of disease, consider specialist review for adjustment of the DMARD dosage.
Some patients with severe symptoms (eg pain and impaired function) may have been started on low-dose oral corticosteroids by their general practitioner while awaiting specialist review. If low-dose oral corticosteroids are ineffective, early specialist review is important; refer to, or discuss with, the specialist promptly. The specialist may advise the general practitioner to start the patient on oral corticosteroids if they have not already done so. If oral corticosteroid therapy is indicated for severe symptoms of RA, the usual initial dosage is:
prednisolone (or prednisone) 5 to 15 mg orally, daily. prednis ol one prednis(ol)one prednis(ol)one
Patients with RA are usually highly steroid sensitive. Doses higher than the recommendations are rarely necessary and associated with more adverse effectsGøtzsche, 2004, 2004Criswell, 2000.
Parenteral administration of corticosteroids is sometimes used, based on a theoretical reduction in overall corticosteroid exposure compared with oral therapyRuyssen-Witrand, 2018. A single dose of intramuscular corticosteroid may have a prolonged effect (up to 8 weeks) and repeat doses are often unnecessary.
If intramuscular corticosteroid therapy is indicated for severe symptoms of RA, the usual dosage is:
methylprednisolone acetate 80 to 120 mg intramuscularly, as a single dose. methylprednisolone acetate methylprednisolone methylprednisolone
Although systemic corticosteroids can rapidly control inflammation, they are inadequate to prevent joint damage and achieve clinical remission in patients with RA. Significant adverse effects also limit their use. When remission or low disease activity is achieved, the specialist should supervise how to reduce the dose and potentially discontinue the corticosteroid. This is not possible in all patients.