Corticosteroids in the treatment of rheumatologic diseases

Current Opinion in Rheumatology

Volumn 8, Issue 3, 1996, Pages 188-194

  Weisman, Michael H ^a  

^a UCSD MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

PREDNISOLONE;

BONE DENSITY; BONE MINERAL; CORTICOSTEROID THERAPY; DRUG EFFICACY; DRUG SAFETY; HUMAN; PRIORITY JOURNAL; REVIEW; RHEUMATIC DISEASE; RHEUMATOID ARTHRITIS;

EID: 0029953909     PISSN: 10408711     EISSN: None     Source Type: Journal    
DOI: 10.1097/00002281-199605000-00004     Document Type: Review

References (15)

1. Kirwan JR: The effect of glucocorticoids on joint destruction in rheumatoid arthritis. N Engl J Med 1995, 333:142-146. This trial demonstrated, unequivocally, that prednisolone at 7.5 mg/d in early-onset RA (disease duration < 2 years) halted the rate of radiographic progression compared with placebo treatment. At the end of 2 years, 22.1% of hands that had no erosions at entry acquired new erosions, compared with 45.6% of such hands in the placebo group (P = 0.007). Further, acute-phase reactants, development of new erosions, and clinical responses appeared to operate independently of each other. This trial will likely provide a benchmark for disease modification in the coming years, requiring new biologic agents to exert a similar influence in order to stake out a claim for disease modification.
2. Van Schaardenburg D, Valkema R, Dijkmans BA, Papapoulos S, Zwinderman AH, Han KH, Pauwels EK, Breedveld FC: Prednisone treatment of elderly-onset rheumatoid arthritis. Arthritis Rheum 1995, 38:334-342. Patients with elderly-onset RA (> age 60) were studied over 2 years for efficacy and toxicity (bone mass measurements) to compare prednisone with chloroquine treatment. Neither drug appeared satisfactory; too many patients required additional second-line therapy. Problems with study design, including entry criteria, preclude drawing conclusions concerning the utility of prednisone as a remittive agent in elderly-onset RA.
3. Van Gestel AM, Laan RF, Haagsma CJ, Van de Putte, LB, Van Riel PL: Oral steroids as bridge therapy in rheumatoid arthritis patients starting with parenteral gold: a randomized double-blind placebo-controlled trial. Br J Rheumatol 1995, 34:347-351. Fast improvement was noted in patients receiving prednisone used as a bridge therapy while awaiting full benefit of intramuscular gold treatment. However, when the drug was tapered to avoid side effects, all of the benefit was lost and patients experienced a clinically significant rebound. This therapy is not recommended.
4. Huppertz HI, Tschammier A, Horwitz A, Schwab O: Intraarticular corticosteroids for chronic arthritis in children: efficacy and effects on cartilage and growth. J Pediatr 1995, 127:317-321. Intra-articular administration of single large doses of depot corticosteroids likely caused long-lasting remission of synovitis in children and adolescents with chronic arthritis; MRI demonstrated a significant regression of pannus and no untoward effects on cartilage.
5. Weisman MH: Should steroids be used in the management of rheumatoid arthritis? Rheum Dis Clin North Am 1993, 19:189-199.
6. Laan FR, Van Riel PL, Van de Putte LB, Van Erning LJ, Van't hof MA, Lemmens JA: Low dose prednisone induced rapid reversible axial bone loss in patients with rheumatoid arthritis. Ann Intern Med 1993, 119:963-968.
7. Weisman MH: Corticosteroids in the treatment of rheumatologic diseases. Curr Opin Rheumatol 1995, 7:183-190.
8. Dunne CA, Moran CJ, Thompson PW: The effect of regular intramuscular corticosteroid therapy on bone mineral density in rheumatoid patients. Scand J Rheumatol 1995, 24:48-49. Monthly injections of corticosteroids as maintenance therapy did not provide a bone-sparing effect compared with daily corticosteroid use.
9. Buckley LM, Leib ES, Cartularo KS, Vacek PM, Cooper SM: Effects of low dose corticosteroids on the bone mineral density of patients with rheumatoid arthritis. J Rheumatol 1995, 22:1055-1059. A large cross-sectional study of bone mineral density in the femoral neck and lumbar spine was performed to assess the effect of low doses of maintenance corticosteroids in RA subjects. Patients taking 5 to 9 mg/d or more than 10 mg/d had significantly lower spine bone mineral density compared with the noprednisone group and with the group receiving 1 to 4 mg/d. This effect remained significant when Health Assessment Questionnaire score, radiologic progression score, disease activity level, disease duration, and functional class were controlled for in the regression equation. This study confirmed the deleterious effect of long-term prednisone use at doses of 5 mg/d or higher in RA subjects.
10. Cooper C, Coupland C, Mitchell M: Rheumatoid arthritis, corticosteroid therapy and hip fracture. Ann Rheum Dis 1995, 54:49-52. In a community-based case control study of RA, corticosteroids, and hip fracture, the investigators found that hip fracture risk doubled in these subjects; the risk of hip fracture in patients with RA was most closely associated with loss of function, but the degree of risk attributed to corticosteroids was independent of functional status.
11. Saito JK, Davis JW, Wasnich RD, Ross PD: Users of low-dose glucocorticoids have increased bone loss rates: a longitudinal study. Calcif Tissue Int 1995, 57:115-119. In an elderly population, low doses of corticosteroids were associated with significantly increased bone loss rates in both men and women, at approximately double to triple the normal age-related bone loss.
12. Lems WF, Jahangier ZN, Jacobs JWG, Bijlsma JWL: Vertebral fractures in patients with rheumatoid arthritis treated with corticosteroids. Clin Exp Rheumatol 1995, 13:293-297. Vertebral deformities were present in almost 60% of outpatients with RA treated long term with low doses of corticosteroids; clinical manifestations of fracture were common.
13. Boonen S, Van Distel G, Westhoven R, Dequeker J: Steroid myopathy induced by epidural triamcinolone injection. Br J Rheumatol 1995, 34:385-386.
14. Dequeker J, Westhoven R: Low dose corticosteroid associated osteoporosis in rheumatoid arthritis and its prophylaxis and treatment: bones of contention. J Rheumatol 1995, 22:1013. These authors review the available data on the effect of low doses of corticosteroids on bone, emphasizing the possibility that loss occurs early and is potentially reversible. This leads them to the conclusion that preventive strategies are imperative and should be based on solid scientific grounds. They recommend an assessment of risk based on patient characteristics such as age, weight, and height as well as information on the bone turnover status of the patient. A specific regimen is proposed.
15. Hahn BH, Mazzaferri EL: Glucocorticoid-induced osteoporosis. Hosp Pract 1995, 8:45. These investigators sound the alarm for preventive strategies and caution the clinician to implement bone preservation methods before attempting disease control with corticosteroids. They suggest that densitometry should be used in conjunction with clinical assessment to determine risk; prophylactic regimens are suggested depending on that risk, recognizing that calcium, vitamin D, and hormone treatments exert their own degree of hazard and should be monitored carefully. Hahn prescribes estrogen for her young female systemic lupus erythematosus patients who suffer iatrogenic menopause. The authors emphasize the critical nature of ostoporosis risk from the first 6 months of high-dose glucocorticoid treatment.