How to properly use steroids in early RA Save

Guidelines differ on the early treatment of RA – ACR suggests not to use glucocorticoids (GC) and EULAR updated recommendations for RA treatment presented at #EULAR2025 continued to suggest early treatment with MTX and glucocorticoids (1). We do know that it is not easy to get a significant minority of RA patients off of prednisone.

Two studies presented in Barcelona at EULAR may help to determine the optimal route of administration of GCs in early RA (ERA).

The first is an analysis from the randomized NORD-STAR trial in ERA (2). They compared the risk of flares in the 3 Rx arms post hoc.

The groups were:

• 1A (“Oral group”) conventional arm used methotrexate plus oral glucocorticoids (started with 20 mg/day, tapered to 5 mg by week 9, and followed the protocol-prescribed discontinuation by week 36),
• 1B (“Injection group”) AKA active conventional treatment received triple therapy (methotrexate, sulfasalazine, hydroxychloroquine) and mandatory intra-articular glucocorticoid injections in swollen joints (maximum 4 joints or maximum 4 mL per visit).

The bDMARD group received methotrexate plus one of the biologics (certolizumab pegol, abatacept, or tocilizumab).

Of note, intra-articular GC injections were allowed in all treatment groups when clinically indicated.

This was a large study of 810 ERA patients. They used a CDAI-defined flare higher after discontinuation of longer-term oral glucocorticoid bridging strategy, compared to bDMARD Rx.

The initial intra-articular injections group had flare rates similar to those bDMARD Rx – despite most IA injections being performed early in RCT. Both the IA steroid triple therapy group (1B) and bDMARD group had LESS flares than 1A (usual MTX+Prednisolone). This suggests to me that flares are less in ERA when GCs are tapered if IA steroids are used especially early in Rx.

The next study is from the CATCH Canadian cohort of 2,222 ERA patients; mean (SD) age was 55 (15), disease duration 5.5 (3) months, 73% were female, and 86% were white, 69% were initially on methotrexate (MTX) at a mean dose of 20.1 (4.2) mg/week. Mean CDAI at baseline and 12-month scores were 26 (14) and 7.5 (8.6). The majority (75%) received no GC; oral-only GC 19%; parenteral-only GC was 5%, and both oral and parenteral was 1%.

Mean CDAI at baseline was lowest in the no GC and highest in those receiving both po and IM/IA steroids (24.1 vs 32.8, p<0.0001) and in between in the other steroid groups. There were no differences among groups at 12 months.

GC at 12 months were:

8% (no GC)
47% (oral)
26% IM/IA
And 63% both

b/tsDMARDs at 1 yr
7% no GC
14% (oral)

Initial use of GC in the ERA CATCH cohort was low with use related to higher baseline disease activity. Among patients with active early RA, those receiving parenteral GC were half as likely to remain on GC at 12 months, compared to those using oral GC. Parenteral GC (IM/IA) may support earlier discontinuation of steroids.

TAKE HOME MESSAGE
I suggest that consideration for GC that are parenteral should be used in order to avoid chronic GCs and when stopping GCs to reduce the chance of flares.

References:

1. Smolen J. Update of 2025 EULAR recommendations for RA
2. OP0327: TAPERING AND DISCONTINUATION OF GLUCOCORTICOIDS IN EARLY RHEUMATOID ARTHRITIS: THE RISK OF FLARE
3. POS0644: USE OF PARENTERAL COMPARED TO ORAL GLUCOCORTICOIDS IN EARLY RHEUMATOID ARTHRITIS IS SUPERIOR FOR CHANCE OF BEING OFF STEROIDS AND ESCALATION OF THERAPY AT 1 YEAR