Glucocorticoid treatment in rheumatoid arthritis.

INTRODUCTION: In spite of its broad use since 1950 the role of low-dose glucocorticoids (GCs) (up to 7.5 mg/day prednisone) in the treatment of rheumatoid arthritis is still controversial. AREAS COVERED: Publications comparing disease-modifying anti-rheumatic drugs (DMARD) plus prednisolone with DMARD monotherapy were reviewed. Most studies reported greater clinical improvement and greater inhibition of damage progression in the prednisone group. These advantages had vanished after 6 - 12 months in most studies. EXPERT OPINION: Several limitations of the studies are discussed. Often the advantage of GC treatment was not clinically important. Long-term data are needed to evaluate the real benefit of GC treatment in relation to its toxicity. Knowing the potential toxicity 'bridging' GC treatment should be reserved for patients at high risk of damage progression; a reliable method to identify these patients is needed. The toxicity of low-dose GC treatment is often played down. The reporting is incomplete. The increased mortality ratio with GC treatment is rarely mentioned. High cumulative doses are a risk factor. A more comprehensive set of toxicity items is urgently needed. Problems of GC treatment are the 'drug addiction' of the patient and the difficulty to reduce or withdraw prednisone.