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Steroids in RA: Friend or foe (or both)?

At 2022 ACR convergence, we saw new and exciting therapies on the horizon for both rheumatoid arthritis and other rheumatic disease. We have come so far from the days of our patients living on massive doses of steroids (well, my predecessors anyway; there were 8 biologics available for RA when I started my training). We still have many patients however who use steroids for our diseases, with increasing data for toxicity, even in low dose. As someone much smarter than me described them, steroids are our best frenemy.

Abstract 2000 presents longer-term follow-up data from the recently published GLORIA trial. The GLORIA trial looked at low-dose add-on prednisolone in patients with RA over the age of 65, showing reduced joint damage and disease activity but at the expense of increased harm outcomes (OR 1.24, 95% CL 1.04). This extension study examined disease activity, flares and signs of adrenal insufficiency after tapering the prednisolone (or placebo) in 3 months following the 2-year trial period. Of 165 total patients, there was only a small difference in the increase in disease activity between the two groups (DAS28 increase difference 0.21, 95% CL -0.01), though disease activity did increase in both groups. There was no significant difference in clinical or biochemical features for adrenal insufficiency.

Abstract 1994 examined the question of whether using upfront steroids in RA predicts the use of steroids and biologic DMARDs later in the course of treatment. In particular, this study speaks to our fear that our patients (and us as clinicians) will become dependent on steroids. This was a retrospective audit of 1404 newly diagnosed RA patients from a single centre in the Netherlands. The authors compared steroid and bDMARD use within the first 1 years in those who used steroids upfront versus those who did not. Of 1240 patients, 51% used steroids upfront (either with or without a DMARD initially). After adjusting for age, sex, ACPA/RF status and disease activity, there was no difference in later steroid use in those who used it upfront compared with those that didn’t. Upfront glucocorticoids was however associated with higher and earlier bDMARD use, which probably reflects disease severity and residual confounding.

As future therapies and more data emerge, we will continue to modify our use of steroids in RA and other rheumatic disease. Perhaps in my lifetime we may even do away with them completely.

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