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Current view of glucocorticoid co-therapy with DMARDs in rheumatoid arthritis

Abstract

Glucocorticoids are widely used anti-inflammatory and immunosuppressive drugs for rheumatoid arthritis (RA). The disease-modifying potential of low to medium doses of glucocorticoids has been reconfirmed in the past decade, and co-administration of DMARDs and glucocorticoids has become standard in many treatment protocols, especially those for early disease stages but also for long-standing RA. The glucocorticoid regimens used range from continuous low doses to intermittent high doses. Studies of the rationale for and clinical use of glucocorticoids as co-therapy with DMARDs in RA have shown that this approach has a place in modern (tight control) treatment strategies, and that glucocorticoid co-therapy has disease-modifying effects during the first 2 years of treatment in patients with early RA. Furthermore, medium and high doses of glucocorticoids are useful for bridging the interval between initiation of DMARDs and onset of their therapeutic effect. Intra-articular glucocorticoids give good local control and have been used in tight control strategies. New glucocorticoid compounds are becoming available for clinical use that might have an enhanced risk:benefit ratio. Better monitoring of glucocorticoid use will also improve this ratio, and help to allay both patient and rheumatologist concerns about treatment-related adverse effects.

Key Points

  • Glucocorticoids have a place in modern (tight control) treatment strategies in rheumatoid arthritis

  • Glucocorticoids have disease-modifying effects during the first 2 years of treatment in early rheumatoid arthritis

  • Medium and high doses of glucocorticoids are useful for bridging the interval between initiation of DMARDs and onset of their therapeutic effect

  • Safe use of glucocorticoids is enabled by adherence to newly developed guidelines, including those for monitoring of adverse effects

  • New glucocorticoid formulations, some in development, offer delayed release, increased local concentrations and reduced adverse metabolic effects, which should improve their risk:benefit ratio

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Figure 1: Clinical effects spectrum of glucocorticoids.
Figure 2: Fewer erosions after glucocorticoid therapy in patients with early RA who also received DMARDs.
Figure 3: Evidence for long-term preventive effects of glucocorticoids on radiographic damage.

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Acknowledgements

The authors' research work is performed within the framework of Project T1-106 of the Dutch Top Institute Pharma.

Charles P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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J. N. Hoes researched data for the article, made a substantial contribution to discussions of the content, wrote the manuscript, and participated in editing and review of the manuscript before submission. J. W. G. Jacobs, F. Buttgereit and J. W. J. Bijlsma contributed equally to all the above aspects of the manuscript.

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Correspondence to Jos N. Hoes.

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F. Buttgereit is a consultant for, and receives grant support from, Merck and Nitec Pharma, and has received lecture fees from Merck, Mundipharma and Nitec Pharma. J. W. J. Bijlsma is a consultant for Nitec Pharma. J. N. Hoes and J. W. G. Jacobs declare no competing interests.

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Hoes, J., Jacobs, J., Buttgereit, F. et al. Current view of glucocorticoid co-therapy with DMARDs in rheumatoid arthritis. Nat Rev Rheumatol 6, 693–702 (2010). https://doi.org/10.1038/nrrheum.2010.179

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