Steroids Save
Transcription
This is Advanced Practice RheumNow. Hi, I'm Jack Cush with RheumNow. In this review, we'll discuss corticosteroids. Corticosteroids are often used throughout medicine and especially in rheumatology where they're often used to fix an urgent problem.
Let's begin with a review of corticosteroids, especially two important quotes. Dr. Peter Merkel from the University of Pennsylvania has been quoted as saying, "Steroids are the best drug we have and the worst drug we have." And I like my quote that you should quote me on: steroids are rapidly effective but chronically dangerous. Those will tell you pretty much everything you need to know when you're going to write a prescription for steroids.
These drugs work by being powerfully anti-inflammatory. They work because they have a very fast onset and a very short half-life. Because of their use and because of the way they work — by inhibiting prostaglandins, lipoxygenase, pro-inflammatory cytokines, proteases, and a number of cellular subsets involved in auto-inflammatory and autoimmune inflammatory disorders — you get rapid control of disease.
These drugs are effective in low doses at 2.5 milligrams a day of prednisone, medium doses up to 20 milligrams a day, and high doses. What we do know are several facts. Steroids are able to cause disease modification in rheumatoid arthritis. Studies have been done head-to-head against placebo and then in combination with other DMARDs. 10 milligrams of prednisone will protect against future development of bony erosions. That's been proven and that's why many people advocate for the use of corticosteroids early on in the treatment of inflammatory arthritis.
The problem is the higher we go the more risk we assume, and sometimes you need to use really high doses to control the situation. But research has also shown that high doses of steroids — by that I mean 40, 60, 80 milligrams of prednisone a day or higher IV doses — that's associated with a higher mortality rate and mortality from infections and serious infections.
Now why do steroids cause more mortality? Well, it's the mortality from the disorder that's so severe you need high-dose steroids. So you're going to die of lupus nephritis and alveolar hemorrhage, not necessarily the high dose of steroids that you use to treat those conditions. But what you should remember is that when you're using really high doses of steroids, as I mentioned, now you're in a situation where you need to worry about the patient and the patient's outcome. This is a high-risk patient.
So what about high-dose steroids? Again, we use this for life-threatening diseases. We usually are talking about 1 milligram or more per kilogram per day. Sometimes that's doses of 40 or 60 or 80 milligrams of prednisone a day. And where would you use that? The indications would be, as I said, life-threatening conditions like systemic necrotizing vasculitis — examples being GPA, EGPA, GCA — also lupus nephritis, neuropsychiatric lupus, idiopathic inflammatory myositis, Still's disease, and ITP, idiopathic thrombocytopenic purpura.
What about pulse steroids? That's another way of using high-dose steroids. We're talking there about IV — could be intramuscular, but parenteral IV is usually what we're talking about — about one gram a day, 1,000 milligrams per day, given for three days in a row. In rheumatology, in neurology, and other conditions, and sometimes hematology, sometimes four or five days in a row. These are suprapharmacologic doses. Indications for their use include lupus nephritis, rapidly progressive glomerulonephritis, alveolar hemorrhage, and neuropsychiatric lupus.
But in most patients the usual dose of prednisone is 5 to 10 milligrams per day. Prednisone comes in the following doses: 1 milligram, 2.5 milligram, 5, 10 milligram, and 50 milligram tablets. Medrol or prednisolone — it's a little more potent, so its lowest dose is 2 milligrams, then 4, 8, 16, and 32 milligram tablets.
Now when you're going to use steroids you need to carefully choose your dose, commit to it, explain why you're using it. And then after you tell the patient why you're going to use steroids, you have to next tell them why this is the most dangerous drug you use and scare them with the side effects. So as I write the prescription, as I say we're going to use this drug in you, I'm going to say, but first let me tell you the scary side effects of steroids. If you stay on this long enough — or longer than I want you to, or at higher doses — you're going to get fat. You're going to get diabetic. You're going to become hypertensive. You're going to get cataracts and lose your vision. You're going to get weak and fall down. You're going to get stomach upset, if not a stomach ulcer. You'll develop edema and swelling and fluid retention and weight gain. You're at higher risk for heart disease. And by that I mean heart attacks and strokes are higher in people on chronic steroids. You don't want to be on chronic steroids, do you? Oh, by the way,
you're also going to get weak bones, osteopenia, osteoporosis, and a high risk of fractures that you don't want. It has a lot of effects on the skin other than causing edema and bloating. You get more bruising. The skin is brittle, friable, thin, and you're going to have acne. Even at your age, when you're on steroids, almost in any dose, you're at higher risk of infections. And by that I mean nonsense infections like URIs and UTIs and the sniffles and colds. But also you're at higher risk of serious hospitalizable infections like pneumonia and meningitis. And even worse you'll be at high risk for rare bizarre infections due to fungus or mycobacteria, TB, and other bizarre bugs that most people don't get.
Steroids will play games with your mind. You'll be more emotional. You'll become manic. You'll become depressed. You'll get psychotic. You'll have horrible dreams. And you won't be able to sleep. When you're on steroids, it's like being on high octane gas. And your motor just doesn't stop. And sleep is a gigantic problem.
So this is what I tell all my patients with the hope that they're going to say, "Whoa, whoa, whoa, doc. Please don't give me that medicine. Why do I have to take it?" And I tell them why they have to take it. But it's short-term therapy. And that's the other caveat here — that because of this increased risk of infection, serious infection. By the way, it's seen with doses of 4 milligrams of prednisone or less per day, you're at higher risk of infection. That's an Annals of Internal Medicine article from 2020 showing in Medicare older patients and in optimum commercial insurance patients, younger patients, 4 milligrams a day or less associated with significantly higher rates of hospitalizable infection. Another study showed that 4 milligrams a day was associated with a higher risk of atrial fibrillation and heart failure.
So even low doses can be a problem but not in everyone. And I think you need to think about the patient. If it's a low-risk patient, meaning the patient's in low disease activity or remission, they have no swollen joints, for instance, and maybe it's a tender joint and very little pain, that person's very unlikely to have complications of disease. And then when you give them low-dose prednisone, they're very unlikely to have complications of prednisone at 5 milligrams a day or less. But if I give 5 milligrams a day or less to someone who's high-risk RA — many swollen joints, high disease activity, deformity, etc., high CRP — yes, even 5 milligrams a day will increase their risk of steroid side effects.
Let's go back to the low-risk patient. What if I use an intermediate dose of 5 to 10 milligrams a day? They're unlikely to have steroid side effects, but it's still possible. But if you're on 10 milligrams a day or more, they're going to get steroid side effects even if they have low-risk disease. So you see that in low-risk disease, you can be a little bit more acceptant of use of steroids. But in high-risk patients, any dose of steroids comes with a risk and you need to think about that.
Another thing to think about, especially with regards to infection, is how important are infections? When we look at rheumatoid arthritis and the risk of a patient with rheumatoid arthritis getting a hospitalizable serious infection like septic arthritis, sepsis, meningitis, or pneumonia, the risk factors are number one the severity and activity of rheumatoid arthritis — how severe, how active, how deforming. Number two is steroids. Any dose of steroids will contribute to serious infection risk. That's followed by comorbidities like lung disease, cutaneous breakdown like ulcers, and then major joint surgery. But steroids are prominent players when it comes to infectious risk.
Who should not get steroids? Someone who has an active serious infection, someone with TB or non-tuberculous mycobacterial infections, someone with fungal or opportunistic infections, especially if it's a systemic fungal infection. People with extended viral infections or life-threatening viral infections should not be treated with steroids. Pneumocystis and candida — those patients should not be treated with steroids.
Two last important points. One is on steroid withdrawal syndrome. When you're withdrawing steroids in your patients, how do you know that when they flare, if the flare is due to the disease that you're treating or due to steroid withdrawal? When you use steroids at physiologic equivalence that will suppress endogenous steroid production — and I mean by that cortisol. At doses of prednisone 4 to 6 milligrams you will suppress the hypothalamic-pituitary axis; there will be less or no secretion of corticotropin-releasing hormone, ACTH, or cortisol. So on steroids for more than four weeks the HPA — hypothalamic-pituitary axis — is totally suppressed, and if you stop steroids that patient can go into
addisonian crisis. So, normally the body produces cortisol very early in the morning in between 3 and 5 a.m. It's a diurnal circadian variation. But when you're on steroids, your body doesn't make it. So, rule number one, if someone's on steroids for less than four weeks, I don't care what dose, you do not need to wean or taper steroids. You can go right back. You can go right off. I'm treating them for poison oak or poison ivy with 60 milligrams for 2 days and 20 milligrams for 7 days. Stop right away. Okay. What if they're on 40 milligrams a day for 30 days? I'd stop right away. The chance of getting Addisonian crisis is really, really rare. It's much more likely when people flare when you're withdrawing steroids that you're causing steroid withdrawal syndrome. And the symptoms of that are fatigue, lethargy, feeling flu-like, arthralgias, myalgias, nausea, anorexia, stiffness, mood swings, and depression. A lot of that sounds like recurrence of the underlying disorder. And you're not going to know if it's the disease and disorder or if it's steroid withdrawal because as soon as you give the steroids back, all that goes away. I just assume it's automatically steroid withdrawal syndrome because I'm not going to withdraw steroids too quickly in people that I'm tapering down.
Let's say I'm going from — let's say it's PMR — from 20 to 15 to 12.5 to 10 to 8, 9, 7, you know, down 1 milligram a day every few weeks at that dose of, say, 6, 7, 8 — they're going to complain, and that could be steroid withdrawal. You go back up to the dose that they didn't complain at and then you have a slower withdrawal regimen.
Addisonian crisis looks different than steroid withdrawal. Abdominal pain, back pain, leg pains that are severe, extreme weakness, nausea, vomiting, diarrhea, dehydration, confusion, hypotension, shock, hypoglycemia, hyponatremia, and hyperkalemia.
When you're adjusting steroids or making steroid equivalents, your body makes about 25 milligrams of hydrocortisone a day, but the equivalents are: 20 of hydrocortisone is equal to 5 of prednisone, and that's equal to 4 milligrams of prednisolone, and that's equal to 0.75 milligrams of dexamethasone.
When you're weaning steroids, if you start at 80 milligrams, decrease by 20 milligrams at 2 to 4 week intervals. I'll go from 80 to 60 to 40, or 80 to 60 and then maybe I go down by 10 milligrams after I get to 50 or 40. Okay? And you go down to 20 milligrams a day. From 20 milligrams to 10 milligrams you decrease by either 5 milligrams or 2.5 milligrams every 2 to 4 weeks depending on the disease. So I'll go from 20 to 15 in PMR for instance. I'll go from 20 to 15 and make my changes every month, and thereafter I'll change every month by 2.5, from 15 to 12.5 and then to 10. And when I get to 10 I'm only going to drop by 1 milligram every month. So with PMR starting out at 20 or 15 you may be on prednisone for 12 to 16 months, but you'll find that you can get off steroids at the end. Way too many of you are stuck on prednisone doses and don't know what to do about it with PMR.
Two important points from ACR and EULAR. ACR guidelines on RA say start methotrexate right away, but don't use steroids unless you have to because they're dangerous and you should only use them short term. EULAR says start them on methotrexate and glucocorticoids as a very strong recommendation, and they say because all of you will wean steroids at some point in the near future and that's the way to go.
Let's end with some steroid pearls. All people going on steroids need to have full disclosure of the adverse events to be expected with extended or excessive use. Secondly, all steroid prescriptions should come with an expiration date. You should say to the patient, you will only be on prednisone for x number of weeks or x number of months or x number of days. Remember that all of our expensive disease-modifying drugs — the biologics, the targeted synthetics, the JAKs — they're supposed to be steroid sparing. Yet the evidence is that when you're using them in these disorders, you're still keeping people on steroids. And I'm talking about RA, PsA, SpA, lupus, PMR, GCA, GPA, EGPA, etc.
Patients undergoing major surgery — gallbladder removal, laparoscopic surgery, pelvic surgery, eye surgery, joint replacement surgery — do you stop their daily steroids? No. You continue the daily steroids because if you wean or stop the steroids, they're going to flare and inflammation is a far greater risk for infection than the steroid that you're using. Keep them on the same dose of steroids. If they're on steroids, you don't also need to use stress dose of steroids. That's been proven to be unnecessary.
Think twice about prescribing steroids over the phone. If you have to, go ahead, but then give them an urgent follow-up visit or a scheduled follow-up visit to check on what you did. If you realize that 5 milligrams is safer than 10 milligrams, then also realize 4 milligrams is safer than 5.
and a 2 milligram is safer than 4 and that being off is better than being on at any dose. Lastly, low-dose steroids do not affect vaccine efficacy, but high-dose steroids do. And again, RA treatment guidelines, I like EULAR guidelines more so than ACR. Start with prednisone and get them off within 8 weeks, 12 weeks at the most. Steroids should always come with an expiration date. Hope you enjoyed it. Look for more advanced practice
Let's begin with a review of corticosteroids, especially two important quotes. Dr. Peter Merkel from the University of Pennsylvania has been quoted as saying, "Steroids are the best drug we have and the worst drug we have." And I like my quote that you should quote me on: steroids are rapidly effective but chronically dangerous. Those will tell you pretty much everything you need to know when you're going to write a prescription for steroids.
These drugs work by being powerfully anti-inflammatory. They work because they have a very fast onset and a very short half-life. Because of their use and because of the way they work — by inhibiting prostaglandins, lipoxygenase, pro-inflammatory cytokines, proteases, and a number of cellular subsets involved in auto-inflammatory and autoimmune inflammatory disorders — you get rapid control of disease.
These drugs are effective in low doses at 2.5 milligrams a day of prednisone, medium doses up to 20 milligrams a day, and high doses. What we do know are several facts. Steroids are able to cause disease modification in rheumatoid arthritis. Studies have been done head-to-head against placebo and then in combination with other DMARDs. 10 milligrams of prednisone will protect against future development of bony erosions. That's been proven and that's why many people advocate for the use of corticosteroids early on in the treatment of inflammatory arthritis.
The problem is the higher we go the more risk we assume, and sometimes you need to use really high doses to control the situation. But research has also shown that high doses of steroids — by that I mean 40, 60, 80 milligrams of prednisone a day or higher IV doses — that's associated with a higher mortality rate and mortality from infections and serious infections.
Now why do steroids cause more mortality? Well, it's the mortality from the disorder that's so severe you need high-dose steroids. So you're going to die of lupus nephritis and alveolar hemorrhage, not necessarily the high dose of steroids that you use to treat those conditions. But what you should remember is that when you're using really high doses of steroids, as I mentioned, now you're in a situation where you need to worry about the patient and the patient's outcome. This is a high-risk patient.
So what about high-dose steroids? Again, we use this for life-threatening diseases. We usually are talking about 1 milligram or more per kilogram per day. Sometimes that's doses of 40 or 60 or 80 milligrams of prednisone a day. And where would you use that? The indications would be, as I said, life-threatening conditions like systemic necrotizing vasculitis — examples being GPA, EGPA, GCA — also lupus nephritis, neuropsychiatric lupus, idiopathic inflammatory myositis, Still's disease, and ITP, idiopathic thrombocytopenic purpura.
What about pulse steroids? That's another way of using high-dose steroids. We're talking there about IV — could be intramuscular, but parenteral IV is usually what we're talking about — about one gram a day, 1,000 milligrams per day, given for three days in a row. In rheumatology, in neurology, and other conditions, and sometimes hematology, sometimes four or five days in a row. These are suprapharmacologic doses. Indications for their use include lupus nephritis, rapidly progressive glomerulonephritis, alveolar hemorrhage, and neuropsychiatric lupus.
But in most patients the usual dose of prednisone is 5 to 10 milligrams per day. Prednisone comes in the following doses: 1 milligram, 2.5 milligram, 5, 10 milligram, and 50 milligram tablets. Medrol or prednisolone — it's a little more potent, so its lowest dose is 2 milligrams, then 4, 8, 16, and 32 milligram tablets.
Now when you're going to use steroids you need to carefully choose your dose, commit to it, explain why you're using it. And then after you tell the patient why you're going to use steroids, you have to next tell them why this is the most dangerous drug you use and scare them with the side effects. So as I write the prescription, as I say we're going to use this drug in you, I'm going to say, but first let me tell you the scary side effects of steroids. If you stay on this long enough — or longer than I want you to, or at higher doses — you're going to get fat. You're going to get diabetic. You're going to become hypertensive. You're going to get cataracts and lose your vision. You're going to get weak and fall down. You're going to get stomach upset, if not a stomach ulcer. You'll develop edema and swelling and fluid retention and weight gain. You're at higher risk for heart disease. And by that I mean heart attacks and strokes are higher in people on chronic steroids. You don't want to be on chronic steroids, do you? Oh, by the way,
you're also going to get weak bones, osteopenia, osteoporosis, and a high risk of fractures that you don't want. It has a lot of effects on the skin other than causing edema and bloating. You get more bruising. The skin is brittle, friable, thin, and you're going to have acne. Even at your age, when you're on steroids, almost in any dose, you're at higher risk of infections. And by that I mean nonsense infections like URIs and UTIs and the sniffles and colds. But also you're at higher risk of serious hospitalizable infections like pneumonia and meningitis. And even worse you'll be at high risk for rare bizarre infections due to fungus or mycobacteria, TB, and other bizarre bugs that most people don't get.
Steroids will play games with your mind. You'll be more emotional. You'll become manic. You'll become depressed. You'll get psychotic. You'll have horrible dreams. And you won't be able to sleep. When you're on steroids, it's like being on high octane gas. And your motor just doesn't stop. And sleep is a gigantic problem.
So this is what I tell all my patients with the hope that they're going to say, "Whoa, whoa, whoa, doc. Please don't give me that medicine. Why do I have to take it?" And I tell them why they have to take it. But it's short-term therapy. And that's the other caveat here — that because of this increased risk of infection, serious infection. By the way, it's seen with doses of 4 milligrams of prednisone or less per day, you're at higher risk of infection. That's an Annals of Internal Medicine article from 2020 showing in Medicare older patients and in optimum commercial insurance patients, younger patients, 4 milligrams a day or less associated with significantly higher rates of hospitalizable infection. Another study showed that 4 milligrams a day was associated with a higher risk of atrial fibrillation and heart failure.
So even low doses can be a problem but not in everyone. And I think you need to think about the patient. If it's a low-risk patient, meaning the patient's in low disease activity or remission, they have no swollen joints, for instance, and maybe it's a tender joint and very little pain, that person's very unlikely to have complications of disease. And then when you give them low-dose prednisone, they're very unlikely to have complications of prednisone at 5 milligrams a day or less. But if I give 5 milligrams a day or less to someone who's high-risk RA — many swollen joints, high disease activity, deformity, etc., high CRP — yes, even 5 milligrams a day will increase their risk of steroid side effects.
Let's go back to the low-risk patient. What if I use an intermediate dose of 5 to 10 milligrams a day? They're unlikely to have steroid side effects, but it's still possible. But if you're on 10 milligrams a day or more, they're going to get steroid side effects even if they have low-risk disease. So you see that in low-risk disease, you can be a little bit more acceptant of use of steroids. But in high-risk patients, any dose of steroids comes with a risk and you need to think about that.
Another thing to think about, especially with regards to infection, is how important are infections? When we look at rheumatoid arthritis and the risk of a patient with rheumatoid arthritis getting a hospitalizable serious infection like septic arthritis, sepsis, meningitis, or pneumonia, the risk factors are number one the severity and activity of rheumatoid arthritis — how severe, how active, how deforming. Number two is steroids. Any dose of steroids will contribute to serious infection risk. That's followed by comorbidities like lung disease, cutaneous breakdown like ulcers, and then major joint surgery. But steroids are prominent players when it comes to infectious risk.
Who should not get steroids? Someone who has an active serious infection, someone with TB or non-tuberculous mycobacterial infections, someone with fungal or opportunistic infections, especially if it's a systemic fungal infection. People with extended viral infections or life-threatening viral infections should not be treated with steroids. Pneumocystis and candida — those patients should not be treated with steroids.
Two last important points. One is on steroid withdrawal syndrome. When you're withdrawing steroids in your patients, how do you know that when they flare, if the flare is due to the disease that you're treating or due to steroid withdrawal? When you use steroids at physiologic equivalence that will suppress endogenous steroid production — and I mean by that cortisol. At doses of prednisone 4 to 6 milligrams you will suppress the hypothalamic-pituitary axis; there will be less or no secretion of corticotropin-releasing hormone, ACTH, or cortisol. So on steroids for more than four weeks the HPA — hypothalamic-pituitary axis — is totally suppressed, and if you stop steroids that patient can go into
addisonian crisis. So, normally the body produces cortisol very early in the morning in between 3 and 5 a.m. It's a diurnal circadian variation. But when you're on steroids, your body doesn't make it. So, rule number one, if someone's on steroids for less than four weeks, I don't care what dose, you do not need to wean or taper steroids. You can go right back. You can go right off. I'm treating them for poison oak or poison ivy with 60 milligrams for 2 days and 20 milligrams for 7 days. Stop right away. Okay. What if they're on 40 milligrams a day for 30 days? I'd stop right away. The chance of getting Addisonian crisis is really, really rare. It's much more likely when people flare when you're withdrawing steroids that you're causing steroid withdrawal syndrome. And the symptoms of that are fatigue, lethargy, feeling flu-like, arthralgias, myalgias, nausea, anorexia, stiffness, mood swings, and depression. A lot of that sounds like recurrence of the underlying disorder. And you're not going to know if it's the disease and disorder or if it's steroid withdrawal because as soon as you give the steroids back, all that goes away. I just assume it's automatically steroid withdrawal syndrome because I'm not going to withdraw steroids too quickly in people that I'm tapering down.
Let's say I'm going from — let's say it's PMR — from 20 to 15 to 12.5 to 10 to 8, 9, 7, you know, down 1 milligram a day every few weeks at that dose of, say, 6, 7, 8 — they're going to complain, and that could be steroid withdrawal. You go back up to the dose that they didn't complain at and then you have a slower withdrawal regimen.
Addisonian crisis looks different than steroid withdrawal. Abdominal pain, back pain, leg pains that are severe, extreme weakness, nausea, vomiting, diarrhea, dehydration, confusion, hypotension, shock, hypoglycemia, hyponatremia, and hyperkalemia.
When you're adjusting steroids or making steroid equivalents, your body makes about 25 milligrams of hydrocortisone a day, but the equivalents are: 20 of hydrocortisone is equal to 5 of prednisone, and that's equal to 4 milligrams of prednisolone, and that's equal to 0.75 milligrams of dexamethasone.
When you're weaning steroids, if you start at 80 milligrams, decrease by 20 milligrams at 2 to 4 week intervals. I'll go from 80 to 60 to 40, or 80 to 60 and then maybe I go down by 10 milligrams after I get to 50 or 40. Okay? And you go down to 20 milligrams a day. From 20 milligrams to 10 milligrams you decrease by either 5 milligrams or 2.5 milligrams every 2 to 4 weeks depending on the disease. So I'll go from 20 to 15 in PMR for instance. I'll go from 20 to 15 and make my changes every month, and thereafter I'll change every month by 2.5, from 15 to 12.5 and then to 10. And when I get to 10 I'm only going to drop by 1 milligram every month. So with PMR starting out at 20 or 15 you may be on prednisone for 12 to 16 months, but you'll find that you can get off steroids at the end. Way too many of you are stuck on prednisone doses and don't know what to do about it with PMR.
Two important points from ACR and EULAR. ACR guidelines on RA say start methotrexate right away, but don't use steroids unless you have to because they're dangerous and you should only use them short term. EULAR says start them on methotrexate and glucocorticoids as a very strong recommendation, and they say because all of you will wean steroids at some point in the near future and that's the way to go.
Let's end with some steroid pearls. All people going on steroids need to have full disclosure of the adverse events to be expected with extended or excessive use. Secondly, all steroid prescriptions should come with an expiration date. You should say to the patient, you will only be on prednisone for x number of weeks or x number of months or x number of days. Remember that all of our expensive disease-modifying drugs — the biologics, the targeted synthetics, the JAKs — they're supposed to be steroid sparing. Yet the evidence is that when you're using them in these disorders, you're still keeping people on steroids. And I'm talking about RA, PsA, SpA, lupus, PMR, GCA, GPA, EGPA, etc.
Patients undergoing major surgery — gallbladder removal, laparoscopic surgery, pelvic surgery, eye surgery, joint replacement surgery — do you stop their daily steroids? No. You continue the daily steroids because if you wean or stop the steroids, they're going to flare and inflammation is a far greater risk for infection than the steroid that you're using. Keep them on the same dose of steroids. If they're on steroids, you don't also need to use stress dose of steroids. That's been proven to be unnecessary.
Think twice about prescribing steroids over the phone. If you have to, go ahead, but then give them an urgent follow-up visit or a scheduled follow-up visit to check on what you did. If you realize that 5 milligrams is safer than 10 milligrams, then also realize 4 milligrams is safer than 5.
and a 2 milligram is safer than 4 and that being off is better than being on at any dose. Lastly, low-dose steroids do not affect vaccine efficacy, but high-dose steroids do. And again, RA treatment guidelines, I like EULAR guidelines more so than ACR. Start with prednisone and get them off within 8 weeks, 12 weeks at the most. Steroids should always come with an expiration date. Hope you enjoyed it. Look for more advanced practice
If you are a health practitioner, you may Login/Register to comment.
Due to the nature of these comment forums, only health practitioners are allowed to comment at this time.