Bridge Prednisone Use Fails to Improve Outcomes Save

A one year, X-ray outcome trial has shown that the initial use of prednisone (high or low dose) in newly treated active early rheumatoid arthritis (RA) did not improve radiographic outcomes.

Early use of glucocorticoids are often used as "bridge therapy" to afford clinical relief while waiting for the delay in DMARD efficacy but has also been advocated as having potential radiographic benefits down stream as well.

This study compared the use of high-dose (HDP) and low-dose prednisolone (LDP) versus placebo in adult RA patients with moderate/high disease activity who were initiating methotrexate therapy. Prednisone was given as either 60 mg (high-dose, HDP), 10 mg prednisolone (low-dose, LDP) daily (tapered to 0 mg within 12 weeks), or placebo. The primary outcome was radiographic change at 1 year measured by the modified Sharp/van der Heijde (mSvdH) score. 

From 395 randomized patients, 95% remained in the modified intention-to-treat analysis.  Patients enrolled in this trial had high disease activity (mean DAS28-ESR of ~6.0, mean of 13 swollen joints and mSvdH score of 5 units).

Radiographic outcomes at the end of one year showed no differences in mean changes to  the mSvdH scores:

• HDP 1.0 (2.0) units
• LDP 1.1 (2.2) units
• Placebo 1.1 (1.5) units

While the mean DAS28 (ESR) differed between HDP/LDP and prednisone groups at week 12 (HDP vs. placebo: –0.6; LDP vs. placebo: –0.8), by week 52, there was no significant difference in DAS28 (ESR) between the 3 groups.

Short-term bridging therapy with prednisone provided no clinical benefits or radiographic protection at one year.  It should be noted that there was little radiographic progression in this trial, making it: a) unlikely to see a benefit, but b) unnecessary to receive bridge therapy given our modern management of RA.