Corticosteroids in rheumatoid arthritis

Effective anti-inflammatory agents but doubts about safety remain
Elaine M Dennison, Wellcome training research fellow and Cyrus Cooper, Professor of rheumatology

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The millennium brings with it the 50th anniversary of Hench's discovery that corticosteroids might be used to treat rheumatoid arthritis.1 Attitudes towards such use have waxed and waned since then.Although rheumatologists claim to use steroids relatively infrequently, audits of patients attending outpatient departments suggest a high prevalence of use (as great as 80%).3,4 What, then, is the quality of the evidence to support the use of corticosteroids in rheumatoid arthritis?This question is best answered by considering the balance between the risks and benefits of steroid use for short periods (two to three months), with the objective of suppressing generalised flares of synovitis, and for longer periods (two years or more) in an attempt to modify the progression of structural disease.Initial hope that steroids might dramatically alter the long term course of the disorder gave way to a recognition of the serious adverse effects that accompany high dose treatment.A recent survey in general practice found that 1.4% of patients aged over 54 were using corticosteroids at a mean dose of 8 mg daily2: rheumatoid arthritis was the indication in 23% of cases.The best controlled data on efficacy and safety originate from long term studies that examine endpoints such as the progression of erosive disease.As a result the use of low dose corticosteroids in arthritis remains highly controversial.Corticosteroids are used widely in medicine today.