ASK DIS: Prednisolone in Rheumatoid Arthritis

Uptodate	· Short-term use of glucocorticoids in doses less than the equivalent of 15 mg of prednisolone per day is seldom associated with serious adverse effects. · Several clinical trials have suggested salutary benefits of high-dose prednisone therapy in early RA. The Combination Therapy Trial in Early Rheumatoid Arthritis (COBRA) and the Behandel Strategieen (BeSt) trial demonstrated that higher-dose oral prednisone (60 mg/day, tapering to 7.5 mg/day by week 6 and then stopping after week 12) in combination with other conventional DMARDs substantially inhibits the progression of radiographic joint damage, and this effect is sustained over many years. · One open-label trial has suggested that lower initial doses of glucocorticoids (prednisone 30 mg daily) may have comparable efficacy to the higher dose used in the classic COBRA regimen · Clinical experience suggests that glucocorticoids continue to be effective for periods up to six months. Pulse Glucocorticoid · Pulse therapy consists of the administration of high doses of glucocorticoids over a short period of time. No studies exist that directly compare this mode of therapy with a regimen of chronic low-dose oral prednisone. · The utility of pulse glucocorticoid therapy among patients with RA has been limited to the following settings: 1. The treatment of acute flares 2. A therapeutic bridge between the initiation of and response to disease-modifying antirheumatic drugs (DMARDs) · The minimum effective dose of methylprednisolone is unknown. The standard "pulse" dose has traditionally been 1000 mg administered intravenously (IV) daily for three consecutive days once monthly, but some evidence suggests that lower doses may be as effective.
CPG Rheumatoid Arthritis 2019	· Prednisolone is preferred over other long-acting corticosteroids (betamethasone, dexamethasone) in the treatment of RA since it causes less inhibition of the hypothalamic-pituitary-adrenal axis. · Long-term use of corticosteroids predisposes to several complications, in particular osteoporosis and infection. Hence patients on corticosteroids should be supplemented with calcium and vitamin D, and have regular surveillance for infection. · In a large, multicentre RCT, inclusion of low-dose prednisolone (10 mg daily) in a methotrexate (MTX)-based treatment strategy for tight control in early RA significantly improved erosion score at two years compared with MTX-placebo. It also improved Disease Activity Score 28 (DAS28) at three and six months.
Current Treatment Strategies for Rheumatoid Arthritis, 2000	· Systemic extra-articular manifestations such as rheumatoid vasculitis may require treatment with initial prednisone dosages of 40 to 60 mg/d, tapering according to response.
ACR 2015	· >10 mg/day of prednisone (or equivalent) and up to 60 mg/day with a rapid taper · Regimen based on that described in the COBRA study
Drugs.com	· Dosing should be individualized based on disease and patient response: · Initial dose: 5 to 60 mg orally per day; may be give once a day or in divided doses · Maintenance dose: Adjust or maintain initial dose until a satisfactory response is obtained; then, gradually in small decrements at appropriate intervals decrease to the lowest dose that maintains an adequate clinical response