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Vol. 19. Issue 10.
Pages 596-597 (December 2023)
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Vol. 19. Issue 10.
Pages 596-597 (December 2023)
Letter to the Editor
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Dosage and time of use of glucocorticoids in rheumatoid arthritis
Dosis y tiempo de empleo de glucocorticoides en artritis reumatoide
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Carlos Abud-Mendoza
Corresponding author
c_abud@hotmail.com

Corresponding author.
, David Alejandro Herrera vanOostdam
Facultad de Medicina de la Universidad Autónoma de San Luis Potosí y Hospital Central “Dr. Ignacio Morones Prieto”, San Luis Potosí S.L.P., Mexico
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Dear Editor,

We have no evidence that short-term glucocorticoid (GC) bridging therapy alters structural changes, although we recognise that it improves symptomatology, despite the fact that a few weeks may not be sufficient to achieve efficacy and alter the natural course of rheumatoid arthritis (RA).1–3

Low-dose GCs (5 mg prednisone [pdn]) alter the natural history of RA; although there are no studies as yet comparing effects on structural changes with ≤5 vs. ≤10 mg/pdn/d.4,5 In addition, it appears that efficacy is similar with the use of 5 mg or less for RA activity even at disease onset, and such doses are safe, even after a decade, in most patients, without modifying adrenal function or response.6,7

In a similar time frame and over a longer period, there is evidence that, out of the adverse events associated with these doses, osteoporosis and infectious processes are the most notable, even at low doses (5 mg/pdn/d or equivalent), and we have not defined a reasonable minimum safe duration to avoid or restrict these effects.8,9 It is clear that the higher the dose and the longer the administration time, the greater the likelihood of these and many other additional adverse events.

On the other hand, it is of highly significant interest that the requirements of low doses of GCs are not limited to their use as bridge therapy for most patients; moreover, it seems that the achievement and maintenance of adequate response (remission or low activity) is achieved with the continued administration of very low doses of steroids.10,11

Thus, despite the potential benefits of the use of GCs in RA, in the face of adverse events we can incorporate these in our therapeutic proposal as a bridge therapy at doses of ≤7.5 mg/pdn/d and longer term, or, indefinitely at maintenance doses of ≤5 mg/pdn/d, even when in remission and with biological therapy.12,13

The authors, research lecturers at the Faculty of Medicine of the Autonomous University of San Luis Potosí and the Regional Rheumatology Unit of the Central Hospital "Dr Ignacio Morones Prieto", certify our commitment to comply with the Code of Ethics, with the objectives of establishing and promoting principles and values, responsibilities and ethical commitments in relation to behaviours and practices to achieve patient benefits and institutional objectives, as well as contributing to the good use of public resources; framed within the Code of Ethics.

Funding

We declare that we have not received any funding.

References
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L. van Ouwerkerk, M. Boers, P. Emery, P.H.P. de Jong, R.B.M. Landewé, W. Lems, et al.
Individual patient data meta-analysis on continued use of glucocorticoids after their initiation as bridging therapy in patients with rheumatoid arthritis.
Ann Rheum Dis, 82 (2023), pp. 468-475
[2]
M. Boers.
Three months of glucocorticoids in rheumatoid arthritis: a bridge too short?.
Arthritis Rheumatol, 74 (2022), pp. 1609-1611
[3]
M. Doumen, S. Pazmino, D. Bertrand, R. Westhovens, P. Verschueren.
Glucocorticoids in rheumatoid arthritis: balancing benefits and harm by leveraging the therapeutic window of opportunity.
[4]
J.R. Kirwan, J.W. Bijlsma, M. Boers, B.J. Shea.
Effects of glucocorticoids on radiological progression in rheumatoid arthritis.
Cochrane Database Syst Rev., 2007 (2007),
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S. Wassenberg, R. Rau, H. Zeidler, Low-Dose Prednisolone Trail Group.
A dose of only 5 mg prednisolone daily retards radiographic progression in early rheumatoid arthritis - the Low-Dose Prednisolone Trial.
Clin Exp Rheumatol, 29 (2011), pp. S68-72
[6]
T. Pincus, T. Sokka, I. Castrejón, M. Cutolo.
Decline of mean initial prednisone dosage from 10.3 to 3.6 mg/day to treat rheumatoid arthritis between 1980 and 2004 in one clinical setting, with long-term effectiveness of dosages less than 5 mg/day.
Arthritis Care Res, 65 (2013), pp. 729-736
[7]
T. Pincus, I. Castrejon, T. Sokka.
Long-term prednisone in doses of less than 5 mg/day for treatment of rheumatoid arthritis: personal experience over 25 years.
Clin Exp Rheumatol, 29 (2011), pp. S130-S138
[8]
O.D. Messina, L.F. Vidal, M.V. Wilman, I.E.M. Bultink, H.G. Raterman, W. Lems.
Management of glucocorticoid-induced osteoporosis.
Aging Clin Exp Res, 33 (2021), pp. 793-804
[9]
M.D. George, J.F. Baker, K. Winthrop, J.Y. Hsu, Q. Wu, L. Chen, et al.
Risk for serious infection with low-dose glucocorticoids in patients with rheumatoid arthritis: a cohort study.
Ann Intern Med., 173 (2020), pp. 870-878
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S.A. Bergstra, A. Sepriano, A. Kerschbaumer, C. John Edwards, D. van der Heijde, R. Caporali, et al.
Efficacy, duration of use and safety of glucocorticoids: a systematic literature review informing the 2022 update of the EULAR recommendations for the management of rheumatoid arthritis.
Ann Rheum Dis., 82 (2023), pp. 81-94
[11]
M. Boers, L. Hartman, D. Opris-Belinski, R. Bos, M.R. Kok, J.A.P. Da Silva, et al.
Low dose, add-on prednisolone in patients with rheumatoid arthritis aged 65+: the pragmatic randomised, double-blind placebo-controlled GLORIA trial.
Ann Rheum Dis., 81 (2022), pp. 925-936
[12]
C. Montecucco, M. Todoerti, G. Sakellariou, C.A. Scirè, R. Caporali.
Low-dose oral prednisone improves clinical and ultrasonographic remission rates in early rheumatoid arthritis: results of a 12-month openlabel randomised study.
Arthritis Res Ther, 14 (2012), pp. R112
[13]
G.R. Burmester, F. Buttgereit, C. Bernasconi, J.M. Álvaro-Gracia, N. Castro, M. Dougados, on behalf of the SEMIRA collaborators, et al.
Continuing versus tapering glucocorticoids after achievement of low disease activity or remission in rheumatoid arthritis (SEMIRA): a double-blind, multicentre, randomised controlled trial.
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Reumatología Clínica (English Edition)
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