The effectiveness of low-dose corticosteroids in the treatment of rheumatoid arthritis disease activity over the moderate term

Low dose corticosteroid use in RA is currently widespread with up to 80% of patients using prednisone or similar corticosteroid preparations in many arthritis practices, but the value of corticosteroids for the treatment of RA has been debated by several authors.

We included studies that used prednisone (or a comparable corticosteroid preparation) at a mean dose of less than or equal to 15 mg per day. We included studies that utilized either placebo controls or active controls (i.e. comparative studies).

Very few studies directly assessed the effectiveness of corticosteroids for RA treatment and many were of poor methodologic quality. Only seven of 34 studies identified by our search met criteria for inclusion. Our results indicated that corticosteroids were significantly more effective than placebo controls for four of six outcomes assessed [standardized mean difference for tender joints = -0.37 (95%CI: -0.59, -0.14), swollen joints = -0.41 (-0.67, -0.16), pain = -0.43 (-0.74, -0.12), and functional status = -0.57 (-0.92, -0.22)]. The results for grip strength and ESR were not significant [GS = +0.30 (-0.19, +0.80), weighted mean difference (WMD) for ESR = -7.03 (-18.06, +4.01)]. The single trial that compared prednisone to aspirin indicated no statistically significant difference between these groups for joint tenderness (0.10 (-0.35, +0.55) and for ESR [0.00 (-11.09, +11.09]. Overall, the four outcomes assessed in the single trial that compared prednisone to chloroquine suggested that there was no statistically significant differenece in the effectiveness of these two agents [SMD for joint tenderness = +0.23 (-0.30, +0.75), swollen joints = +0.43 (-0.11, +0.96), functional status = -0.27 (-0.80, +0.26), and WMD for ESR = -16.00 (-30.58, -1.42)].

Authors' conclusions: 

Based on the limited data available, moderate-term prednisone treatment of RA appears to be superior to placebo and comparable to treatment with aspirin or chloroquine in improving several common rheumatoid arthritis disease activity measures.

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Background: 

Low dose corticosteroid use in RA is currently widespread with up to 80% of patients using prednisone or similar corticosteroid preparations in many arthritis practices, but the value of corticosteroids for the treatment of RA has been debated by several authors.

Objectives: 

To perform a systematic review of low-dose corticosteroid efficacy in the moderate term for the treatment of rheumatoid arthritis (RA).

Search strategy: 

We searched MEDLINE from 1966 to 1998, using the keywords "corticosteroids" and "rheumatoid arthritis". We also handsearched all issues of Arthritis and Rheumatism and the Scandinavian Journal of Rheumatology from their dates of first publication to 1994 and examined all Arthritis and Rheumatism abstracts over the 15 year period preceding 1994. References of all identified studies were searched for relevant trials. Authors of unpublished manuscripts were contacted.

Selection criteria: 

We required that trials be randomized or cross-over and report at least one of the outcome measures of interest. We also required that trials be of at least three months duration and use prednisone (or a comparable corticosteroid preparation) at a mean dosage of less than or equal to 15 mg/day, compared to placebo or active drug controls.

Data collection and analysis: 

Data was abstracted by two independent reviewers (LC, KS) using a standard form. We reported results for all available outcomes recommended by the Outcome Measures for Rheumatology Trials (OMERACT) group.

Main results: 

Very few studies directly assessed the effectiveness of corticosteroids for RA treatment and many were of poor methodologic quality. Only seven of 34 studies identified by our search met criteria for inclusion. Our results indicated that corticosteroids were significantly more effective than placebo controls for four of six outcomes assessed [standardized mean difference for tender joints = -0.37 (95%CI: -0.59, -0.14), swollen joints = -0.41 (-0.67, -0.16), pain = -0.43 (-0.74, -0.12), and functional status = -0.57 (-0.92, -0.22)]. The results for grip strength and ESR were not significant [GS = +0.30 (-0.19, +0.80), weighted mean difference (WMD) for ESR = -7.03 (-18.06, +4.01)]. The single trial that compared prednisone to aspirin indicated no statistically significant difference between these groups for joint tenderness (0.10 (-0.35, +0.55) and for ESR [0.00 (-11.09, +11.09]. Overall, the four outcomes assessed in the single trial that compared prednisone to chloroquine suggested that there was no statistically significant differenece in the effectiveness of these two agents [SMD for joint tenderness = +0.23 (-0.30, +0.75), swollen joints = +0.43 (-0.11, +0.96), functional status = -0.27 (-0.80, +0.26), and WMD for ESR = -16.00 (-30.58, -1.42)].

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