How is prednisone used to treat inflammatory arthritis. What are the typical dosages for prednisone in arthritis treatment. What are the potential side effects of using prednisone for arthritis.

Understanding Prednisone: A Powerful Corticosteroid for Arthritis Treatment

Prednisone is a synthetic corticosteroid widely used in the treatment of various inflammatory conditions, including several types of arthritis. As a potent anti-inflammatory medication, it plays a crucial role in managing symptoms and slowing disease progression for many patients. However, its use comes with both benefits and potential risks that need to be carefully considered.

What is Prednisone?

Prednisone belongs to a class of drugs known as corticosteroids. These medications mimic the effects of cortisol, a hormone naturally produced by the adrenal glands. By suppressing the immune system and reducing inflammation, prednisone can effectively alleviate symptoms associated with various inflammatory conditions.

How Does Prednisone Work?

The mechanism of action for prednisone involves suppressing the body’s immune response. It achieves this by:

• Reducing the activity of inflammatory substances in the body
• Inhibiting the production of inflammatory chemicals
• Decreasing the number of immune cells that contribute to inflammation

This multi-faceted approach helps to reduce pain, swelling, and stiffness in affected joints, ultimately improving daily function and potentially preventing long-term joint damage.

Types of Arthritis Treated with Prednisone

Prednisone is primarily used to treat inflammatory types of arthritis. These include:

• Rheumatoid arthritis
• Psoriatic arthritis
• Lupus
• Polymyalgia rheumatica

It’s important to note that prednisone is not typically recommended for the management of osteoarthritis, as this condition is not primarily driven by inflammation.

Why is Prednisone Effective for These Types of Arthritis?

The effectiveness of prednisone in these conditions stems from its powerful anti-inflammatory properties. In autoimmune forms of arthritis, such as rheumatoid and psoriatic arthritis, the immune system mistakenly attacks the body’s own tissues, leading to inflammation and joint damage. By suppressing this overactive immune response, prednisone can help control symptoms and slow disease progression.

Administration and Dosage of Prednisone

Prednisone is typically administered orally, with specific dosing regimens tailored to each patient’s needs.

When Should Prednisone Be Taken?

For optimal effectiveness and to mimic the body’s natural cortisol production, prednisone is usually taken in the morning. This timing aligns with the body’s natural cortisol levels, which are highest in the morning and lowest in the evening.

What Are Typical Prednisone Dosages for Arthritis?

The dosage of prednisone can vary widely depending on the specific condition being treated and the individual patient’s needs. Generally, dosages fall into the following ranges:

• Low dose: 1-10 mg daily
• Moderate dose: 10-20 mg daily
• High dose: 20 mg or more daily

Healthcare providers will work to find the lowest effective dose to minimize potential side effects while still achieving therapeutic benefits.

The Onset of Action: How Quickly Does Prednisone Work?

One of the advantages of prednisone is its rapid onset of action. Many patients experience relief from symptoms within a short time frame after starting treatment.

How Soon Can Patients Expect to Feel the Effects of Prednisone?

The effects of prednisone are often noticed quite quickly:

• Some patients may feel improvements within hours of taking the first dose
• Most patients experience significant relief within 1-4 days
• The full anti-inflammatory effects may take up to a week to manifest

The speed of onset depends on various factors, including the dose prescribed and the severity of inflammation being treated.

Precautions and Contraindications for Prednisone Use

While prednisone can be highly effective, there are situations where its use may be contraindicated or require special precautions.

Who Should Avoid Taking Prednisone?

Prednisone should be avoided or used with extreme caution in patients with:

• A history of allergic reactions to prednisone or other corticosteroids
• Systemic fungal infections
• Active infections, as prednisone can suppress the immune system
• Certain medical conditions that may be exacerbated by corticosteroid use

What Precautions Should Be Taken When Using Prednisone?

Patients taking prednisone should be aware of several important precautions:

1. Never stop prednisone abruptly without medical supervision, especially if you’ve been taking it for more than three weeks
2. Inform your healthcare provider about any infections or symptoms of infection while taking prednisone
3. Discuss any upcoming surgical procedures with your doctor, as your prednisone dosage may need to be adjusted
4. Be aware of potential drug interactions and inform all healthcare providers about your prednisone use
5. Monitor for side effects and report any concerns to your healthcare provider promptly

Potential Side Effects of Prednisone Treatment

While prednisone can be highly effective in managing inflammatory arthritis, it’s associated with a range of potential side effects, particularly with long-term use or high doses.

What Are the Common Side Effects of Prednisone?

Common side effects of prednisone may include:

• Increased appetite and weight gain
• Mood changes, including irritability or euphoria
• Insomnia or sleep disturbances
• Fluid retention and swelling
• Increased blood pressure
• Elevated blood sugar levels
• Gastrointestinal issues, such as nausea or indigestion
• Increased risk of infections

What Long-Term Side Effects Should Patients Be Aware Of?

Prolonged use of prednisone can lead to more serious side effects, including:

• Osteoporosis (weakening of bones)
• Cataracts or glaucoma
• Increased risk of cardiovascular disease
• Adrenal suppression
• Muscle weakness
• Skin thinning and easy bruising
• Delayed wound healing

It’s crucial for patients to work closely with their healthcare providers to monitor for these potential side effects and adjust treatment as necessary.

Managing Prednisone Treatment: Tips for Patients

To maximize the benefits of prednisone while minimizing potential risks, patients should follow certain guidelines and best practices.

How Can Patients Optimize Their Prednisone Treatment?

Consider the following tips for managing prednisone treatment:

1. Take prednisone exactly as prescribed, typically in the morning
2. Never adjust your dose or stop taking prednisone without consulting your healthcare provider
3. Maintain a healthy diet low in sodium and high in calcium and vitamin D to support bone health
4. Engage in regular weight-bearing exercise to help prevent bone loss
5. Monitor your weight and blood pressure regularly
6. Practice good sleep hygiene to minimize sleep disturbances
7. Be vigilant about infection prevention, including regular hand washing and avoiding sick contacts
8. Attend all scheduled follow-up appointments and laboratory tests

What Should Patients Discuss with Their Healthcare Providers?

Open communication with healthcare providers is crucial. Patients should discuss:

• Any new symptoms or side effects experienced
• Concerns about long-term use or desire to taper off prednisone
• Alternative treatment options or combination therapies
• Strategies for managing potential side effects
• Any plans for pregnancy, as prednisone use during pregnancy requires careful consideration

Alternatives and Complementary Treatments to Prednisone

While prednisone can be highly effective, healthcare providers often explore other treatment options to minimize long-term corticosteroid use.

What Are Some Alternatives to Prednisone for Treating Inflammatory Arthritis?

Depending on the specific condition and patient factors, alternatives may include:

• Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate or sulfasalazine
• Biologic agents that target specific components of the immune system
• Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation management
• Targeted synthetic DMARDs like JAK inhibitors
• Intra-articular corticosteroid injections for localized joint inflammation

Can Lifestyle Modifications Complement Prednisone Treatment?

Yes, several lifestyle modifications can support prednisone treatment and overall arthritis management:

1. Regular low-impact exercise to maintain joint flexibility and muscle strength
2. Stress reduction techniques such as meditation or yoga
3. Maintaining a healthy weight to reduce stress on joints
4. following an anti-inflammatory diet rich in fruits, vegetables, and omega-3 fatty acids
5. Using assistive devices to protect joints during daily activities
6. Applying heat or cold therapy for symptom relief

These lifestyle modifications can potentially help reduce the need for high doses of prednisone and improve overall quality of life for patients with inflammatory arthritis.

Prednisone to treat inflammatory types of arthritis

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Drug Name

Prednisone

Brand Name(s)

Winpred®, generics

Drug Class

Corticosteroid

Prednisone is a steroid used to treat inflammatory types of arthritis, such as rheumatoid and psoriatic arthritis, lupus and polymyalgia rheumatic.

• What types of arthritis is prednisone used for?

  Prednisone is a steroid used to treat inflammatory types of arthritis, such as rheumatoid and psoriatic arthritis, lupus and polymyalgia rheumatic.

  Prednisone is not recommended in the management of osteoarthritis.

• How is prednisone administered?

  Prednisone is taken orally.

  Prednisone should be taken in the morning, when it more closely resembles the body’s natural release of steroid hormone (cortisol), which is high in the morning and low in the evening.

• What is the typical dose and when do I take it?

  The dose of prednisone varies widely and is based on your disease and the goals of treatment established by you and your health-care provider. Therefore, there is really no standard dose. Lower doses of prednisone (i.e., 1-10 mg daily) may be sufficient for certain types of inflammatory arthritis, while higher doses (20 mg per day and upwards) may be needed in other cases.

• How does it work?

  Prednisone is a synthetic corticosteroid that has anti-inflammatory properties. It works to suppress the body’s immune system by reducing the activity of inflammatory substances in the body. By doing this, prednisone can help to reduce pain and swelling in the joints, improve day-to-day function, and prevent long term damage to the joints.

• How long will it take to work?

  Prednisone generally works very quickly — usually within one to four days — if the prescribed dose is adequate to reduce your particular level of inflammation. Some people notice the effects of prednisone hours after taking the first dose.

• When should I not take prednisone and call my doctor?

  Prednisone mimics the anti-inflammatory action of cortisol in our bodies.  Cortisol is a steroid hormone produced naturally by our body’s adrenal glands that has many functions, including anti-inflammatory effects.  If you take prednisone for longer periods of time your body starts to adjust and decreases the production of cortisol.  Stopping prednisone too quickly can sometimes cause side effects (e.g. loss of appetite, fatigue, nausea, fever, lethargy) as our body needs time to start making cortisol again.  In very rare cases stopping prednisone too quickly may cause an adrenal crisis, a serious condition which requires immediate medical attention.   If you have taken prednisone for longer than three weeks your healthcare provider will likely recommend a gradual decrease of your dose.  This will allow your body to recognize it needs to start producing its own cortisol again.  Call your prescriber before making any changes to your prednisone dose.

  Prednisone can make it hard for your body to fight infections. Therefore, if you have an infection, your prescriber may avoid giving you prednisone. If you develop symptoms of an infection (i.e., fever or chills) while taking prednisone, please contact your prescriber.

  You may need to alter your dose of prednisone before and after surgical procedures.  Please discuss this with your healthcare provider.

  If you have been taking prednisone for longer than 3 weeks, please contact your healthcare provider if you develop any conditions that may affect the amount of prednisone absorbed from your stomach (e.g., food poisoning, stomach bug, prolonged vomiting or diarrhea).

  Call your prescriber right away if you develop new severe groin pain. (This may be associated with a very rare side effect of prednisone).

• Is there anybody who should not take prednisone?

  Avoid taking prednisone if you have had an allergic reaction to this medication. People with systemic fungal infections should also avoid this medication. 

• What are the side effects of prednisone?

  Prednisone acts quickly and effectively to decrease inflammation, but adverse effects are a major limitation to long-term use. Not all side effects occur in everyone. Most side effects are more commonly associated with use of higher doses for prolonged periods of time and disappear with the decrease and discontinuation of prednisone.

  Prednisone can increase your appetite, which can lead to weight gain. When taken for long periods of time prednisone can cause you to lose calcium from your bones, which can lead to weakened bones and osteoporosis if not appropriately managed.  

  Prednisone can cause nausea, indigestion, increased blood pressure, fluid retention, increased blood sugars, glaucoma, cataracts, difficulty sleeping, mood swings, increased cholesterol and skin changes (acne, or make your skin thinner, more easily damaged and slow to heal).

  If you will be taking prednisone for a prolonged period of time obtain a MedicAlert® bracelet (www.medicalert.ca/1.800.668.1507).  Please discuss this with your healthcare provider.

• What helps to reduce side effects?

  The lowest dose of prednisone that controls symptoms should be used to reduce adverse effects. The duration of steroid use should also be limited. High-dose prednisone bursts often are used to suppress disease flares. High doses are used for several days until symptoms are controlled, followed by a taper to the lowest effective dose.

  To avoid weight gain while taking prednisone, follow a healthy diet and, if possible, exercise regularly.

  To prevent calcium loss from bones, if you are taking prednisone regularly it is important to take extra calcium and vitamin D. Please speak to your healthcare provider about how much you need. If you are taking prednisone for longer periods of time (7.5 mg prednisone or more per day for longer than three months, or less if other risk factors are present) your prescriber may want you to take a medication to help harden your bones (i.e. alendronate, risedronate).

  Taking prednisone with food or milk can help reduce nausea and indigestion. 

  If you experience difficulty sleeping while taking prednisone, make sure you are taking prednisone in the morning and avoid taking the medication in the evening or close to bed time.

• Do I need any monitoring while taking prednisone?

  Routine blood tests may not be required while you are taking prednisone. However, if you are taking prednisone for longer periods of time (more than three months) your prescriber will likely request regular blood work to monitor for blood sugar changes and increased cholesterol and periodic bone mineral density (BMD) tests of your bones. Your prescriber will also monitor for vision changes if you are taking prednisone long-term.

  Your prescriber may also want to meet with you regularly to monitor your blood pressure and to evaluate whether you need to continue taking prednisone.

• How should I store prednisone?

  Store this medication at room temperature (15 to 30 degrees Celsius) and keep it out of reach of children.

This information was written in June 2019, with expert advice from:

Jason Kielly, B.Sc. (Pharm.), Pharm.D.

Associate Professor, School of Pharmacy, Memorial University of Newfoundland

Clinical Pharmacist, Rheumatic Health Program, Eastern Health

This information was last updated in December 2021 by:

Alan Low, B.Sc. (pharm.), Pharm. D., ACPR, FCSHP, CCD, RPh

Clinical Associate Professor, Faculty of Pharmaceutical Sciences, UBC

Co-Founder and Executive Director, Medicines Access Coalition – BC

​Primary Care Pharmacist, Vancouver

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Prednisone for psoriatic arthritis: Dosage and benefits

Psoriatic arthritis (PsA) is a form of inflammatory arthritis that occurs when the immune system mistakenly attacks healthy tissue in the joints. These attacks trigger inflammation, which leads to joint pain, swelling, and stiffness.

Prednisone is a type of corticosteroid medication that helps reduce systemic inflammation. Doctors may prescribe prednisone in combination with other treatments to help alleviate PsA symptoms and control the progression of the disease.

This article describes what prednisone is and how it may help with PsA. It also provides information on how doctors prescribe prednisone and the possible side effects of this medication.

Prednisone belongs to a class of medications called corticosteroids. These anti-inflammatory medications are synthetic versions of hormones that the adrenal glands produce.

Doctors may prescribe corticosteroids to help suppress the immune system or alleviate swelling and inflammation. Some conditions that corticosteroids may help treat include:

• inflammatory forms of arthritis, such as PsA and rheumatoid arthritis
• inflammatory bowel disease
• certain autoimmune conditions
• asthma
• allergic rhinitis
• hives
• atopic eczema
• multiple sclerosis

Prednisone is available under the following brand names:

• Rayos
• Sterapred
• Deltasone

Each of these medications is available as an immediate-release tablet, a delayed-release tablet, or a liquid solution.

PsA is an autoimmune condition in which the body’s immune system mistakenly attacks healthy tissue, causing inflammation. In PsA, this inflammation triggers joint pain, swelling, and stiffness, and it may also cause a skin rash. Over time, this systemic inflammation can lead to permanent joint and tissue damage.

A doctor may prescribe prednisone to help suppress the overactivity of the immune system and reduce the production of chemicals that trigger inflammation. In these ways, the drug helps alleviate joint pain, swelling, and stiffness.

An older case study from 2013 suggested that early PsA treatment combining corticosteroids and disease-modifying antirheumatic drugs (DMARDs) could improve outcomes for people with PsA. Specifically, it may have the following benefits:

• controlling joint inflammation in its early stages
• preventing joint damage
• maintaining long-term functional capacity and quality of life

People who take prednisone usually take it orally, as a tablet. Doctors recommend taking prednisone in the morning because it closely resembles the natural hormone cortisol, which is at its peak early in the day.

The severity of a person’s symptoms and their individual treatment goals will determine the amount of prednisone that they need to take. The optimal dosage will also depend on whether the person has any other underlying conditions.

According to the Arthritis Foundation, people who have liver scarring, called cirrhosis, or an underactive thyroid, known as hypothyroidism, may require a lower dosage.

Generally, the initial starting dosage of oral prednisone is 5–60 milligrams (mg) a day. A doctor may adjust or maintain the daily dose until they are satisfied that PsA is well-controlled. They will then gradually reduce the daily dose in small increments to establish the lowest dosage necessary to manage the condition effectively.

The authors of a 2013 case study reported that a combination of DMARDs and alternate-day low dose prednisone significantly improved one individual’s severe PsA symptoms within a week. Tapering the initial prednisone dose from 10 mg to 2.5 mg on alternate days helped control the disease in the longer term. This, in turn, helped prevent joint damage and improve the person’s quality of life.

If a person requires long-term treatment, their doctor may prescribe prednisone every other day. However, doctors may recommend daily prednisone treatment during PsA flare-ups.

If a person needs to come off prednisone, their doctor will taper the dosage gradually to prevent withdrawal symptoms.

The higher the dosage of prednisone and the longer a person takes it, the higher the risk of adverse side effects. A lower prednisone dosage of 20 mg or less daily is associated with a decreased risk of side effects.

However, not everyone who takes prednisone will experience side effects. When side effects do occur, they typically disappear as the dosage decreases or the treatment stops.

Common side effects of prednisone include:

• weight gain
• nausea and indigestion
• insomnia
• nervousness or restlessness
• increased sweating

According to the Arthritis Foundation and the Canadian Arthritis Society, prednisone may also cause the following side effects:

• high blood pressure
• high cholesterol
• increased blood sugar
• increased risk of infection
• thin skin
• acne
• bruising
• cataracts
• glaucoma
• headaches
• mood swings
• stomach ulcers
• muscle weakness
• irregular periods
• osteoporosis, which is a weakening of the bones
• atherosclerosis, which is a hardening of the arteries
• cardiovascular problems, including heart attack and stroke

People can take steps to reduce the risk of certain side effects while taking prednisone. These steps include:

• eating a nutritious diet and exercising regularly to avoid weight gain
• taking the medication with food or milk to offset feelings of nausea or indigestion
• taking the medication in the morning to help reduce the risk of insomnia

Can prednisone make PsA worse?

At the time of writing, there is no reliable, recent evidence to suggest that taking prednisone or another corticosteroid may worsen PsA.

Prednisone may interact with other drugs, supplements, or herbal remedies. These interactions may be harmful or affect how well the medication works.

People who are taking any of the following medications should speak with their doctor before taking prednisone:

• nonsteroidal anti-inflammatory drugs (NSAIDs)
• mifepristone (Mifeprex)
• bupropion (Wellbutrin)
• haloperidol (Haldol)
• diabetes medication
• warfarin (Jantoven)
• digoxin (Lanoxin)

People who are taking prednisone should also avoid live vaccines, as prednisone can weaken the immune system.

Learn more about medications that may interact with prednisolone.

A person who is taking prednisone should call their doctor immediately if they experience any of the following:

• Symptoms of an infection:
  • fever
  • chills
  • sore throat
  • ear or sinus pain
  • a wound that will not heal
• Symptoms of high blood sugar:
  • sleepiness or confusion
  • excessive thirst or hunger
  • passing urine more often than usual
  • fast breathing
  • fruity-smelling breath
• Symptoms of Cushing’s syndrome:
  • weight gain in the upper back or belly
  • puffy face
  • severe headaches
  • slow wound healing
• Symptoms of adrenal gland problems:
  • weight loss
  • nausea
  • vomiting
  • dizziness
  • muscle weakness
  • fatigue
  • mood changes
• Symptoms of low potassium:
  • muscle pain or weakness
  • cramps
  • abnormal heartbeat
• Symptoms of pancreas problems:
  • severe stomach or back pain
  • nausea
  • vomiting

A person should seek immediate medical attention if they experience any of the following while taking prednisone:

• breathlessness
• swelling of the limbs
• eyesight changes or disturbances
• unusual bleeding
• black or brown vomit, or blood in the vomit
• black stool

Rarely, prednisone may trigger a serious allergic reaction called anaphylaxis. People who experience any of the following symptoms of anaphylaxis will need emergency medical care:

• problems with breathing or talking
• swelling of the face, lips, or throat
• fast heart rate
• dizziness or fainting

Prednisone is a corticosteroid medication that helps suppress an overreactive immune system and control inflammation. Doctors may prescribe prednisone to treat a range of autoimmune or inflammatory conditions, including psoriatic arthritis.

In combination with first-line PsA treatments, prednisone can help control joint pain and inflammation and prevent permanent joint damage. Due to these effects, it may ultimately help improve a person’s quality of life.

Prednisone has the potential to cause side effects. Anyone who experiences concerning side effects should seek medical attention as soon as possible to prevent complications.

Psoriatic arthritis – Skin and allergic diseases

In the 1930s, oil tycoon John Rockefeller, who suffered for many years from psoriasis complicated by psoriatic arthritis, announced that he would pay a personal “Nobel Prize” of $ 1,000,000 to anyone who would find a cure for these ailments. Since then, astronomical interest has increased on this amount, so that the discoverer of “life without psoriasis” will become a rich man. Well, nowadays it has already become possible to achieve remission and return to a full life.

The nature of this disease remains a mystery to researchers, and the means available to modern medicine only help stop the disease, not cure it. Therefore, it is especially important not to start the disease, and start treatment as early as possible, until the diagnosis of psoriatic arthritis becomes a sentence. The sooner you start, the more likely you are to restore the activity of the affected joints!

So, the treatment that the doctor will prescribe for psoriatic arthritis will be aimed at:

• the maximum possible delay in the development of the disease;
• elimination of acute symptoms;
• normalization of the function of the musculoskeletal system;
• reduction of inflammatory and immune responses.

Of course, a healthy lifestyle plays a big role in maintaining a full life for a patient with psoriatic arthritis: proper nutrition, rational physical activity, exercise therapy, physiotherapy and spa treatment (out of the exacerbation phase). But if you want to achieve remission, the use of drugs cannot be avoided!

IMPORTANT! The question of how to treat psoriatic arthritis should be decided individually for each patient.

With the participation of both a dermatologist and a rheumatologist! To make the most accurate diagnosis, examination is a must!

groups of drugs used in the treatment of psoriatic arthritis

• Non-steroidal anti-inflammatory drugs (NSAIDs): voltaren, dichlofenac, ortofen, acyclofenac, piroxicam, meloxicam, celebrex.
• Glucocorticoids for intra-articular administration (IGC): disprospan, depomedrol and others.
• Basic anti-inflammatory drugs (standard therapy): methotrexate, sulfasalazine, leflunomide, cyclosporine.
• Targeted synthetic anti-inflammatory drugs: apremilast.
• Genetically engineered biological products (GEBD): etanercept, infliximab, adalimumab, ustekinumab and others.

More about drug groups

Non-steroidal anti-inflammatory drugs (NSAIDs)

These drugs are recommended to reduce the pain symptoms of arthritis, enthesitis, dactylitis and spondylitis. Usually they are used in high doses for a long time (from two to six months) in conjunction with basic drugs (methotrexate, etc.) and glucocorticoids. But the appointment of NSAIDs for psoriatic arthritis requires caution, since these drugs are included in a number of medications that can provoke an exacerbation of skin psoriasis.

Intra-articular glucocorticoids

In case of limited joint damage, acute dactylitis, heel enthesopathy, intra-articular injections of glucocorticoids are widely used, most often in combination with basic anti-inflammatory therapy.

Systemic treatment with glucocorticoids is usually not carried out due to the high risk of exacerbation of the course of skin psoriasis, as well as a large percentage of adverse events (a sharp increase in body weight, a decrease in muscle tissue mass, an increase in intraocular pressure, etc.) Injections are carried out alternately in the affected joints until the signs of arthritis disappear. Preference is given to long-acting drugs (diprospan, depomedrol). Slow absorption of intra-articular glucocorticoids provides a local anti-inflammatory effect, and can also affect the state of other joints.

Basic anti-inflammatory drugs (standard therapy)

Despite the mystery of the origin and development of psoriasis and associated PsA, most scientists and physicians believe that these diseases are based on immune inflammation. Therefore, they are treated primarily with anti-inflammatory drugs. The main drugs belonging to this group are methotrexate and leflunomide. The first quickly relieves inflammation, the second slows down the destruction of cartilage and inhibits the process of erosion of peripheral joints.

Methotrexate is the most commonly prescribed drug for moderate-to-severe peripheral psoriatic arthritis because it has been well studied, affordable, and has been in use for over 50 years. However, patients receiving such therapy should constantly monitor the functions of the liver and kidneys, and in case of abnormalities, reduce the dose or stop the drug altogether. In 15% of patients with psoriatic arthritis, it is possible to obtain complete clinical remission, and in 60% – partial, which is a very high result. To minimize the risks associated with the use of this drug, it is necessary to have regular examinations and follow the recommendations of the doctor. The doctor selects the regimen and dose of methotrexate for each patient individually.

In the presence of contraindications (or poor tolerance) of treatment with methotrexate, drugs such as leflunomide, sulfasalazine, cyclosporine are prescribed no unwanted side effects).

Leflunomide was originally developed for the treatment of rheumatoid arthritis, it has an anti-inflammatory, immunomodulatory effect, and also inhibits the process of unwanted tissue growth. Leflunomide reduces the manifestations of arthralgia, reduces swelling in the joints, slows down their destruction, while having a better tolerability profile compared to methotrexate, although not in all patients. Some react to it with hair loss (alopecia), diarrhea, etc. Influencing the joints, leflunomide is much less active in relation to the skin manifestations of psoriasis. Therefore, most often, it is prescribed in combination with other drugs.

Sulfasalazine has an anti-inflammatory and antibacterial effect and, like leflunomide, is more active on the joints than on the skin. This drug has many contraindications, and the question of its appointment should be decided on an individual basis.

It should be noted that psoriatic arthritis has many manifestations: it can affect both the central skeleton, that is, the spine and pelvic bones, and maybe peripheral large and small joints of the arms and legs. Therapy with traditional drugs is effective against peripheral arthritis and has virtually no effect on the severity of symptoms and the rate of development of spondylitis, intra-articular osteolysis, enthesitis or dactylitis.

Targeted synthetic anti-inflammatory drugs

This class of drugs with an intracellular mechanism of action due to the small size of the molecules of the active substance, in our country is represented by the drug apremilast, which blocks signals from cells that provoke inflammatory processes in the joints and skin.

Apremilast is prescribed for intolerance / contraindications to basic therapy.

Genetically engineered biological products (GIBPs)

Drugs in this class, such as etanercept, infliximab, adalimumab and ustekinumab and others, inhibit (block) tumor growth, eliminating the symptoms of the disease. Most often, they are used to treat the most “difficult” patients, in whom the manifestations of PsA threaten to turn into disability and a complete loss of the ability to move and live a full life. Those. when other therapy fails. Biological therapy is associated with an increased risk of infectious diseases. For this reason, infections, including tuberculosis, must be ruled out in the patient. Over time, the use of genetically engineered drugs may develop secondary treatment failure (the so-called “escape effect”), since the patient’s body begins to produce neutralizing antibodies.

The creation of a specific cure for psoriatic arthritis is a matter of the near future, but even now you should not give up after hearing such a diagnosis, the disease will not go away if you do not do it. Dispassionate statistics data are as follows: the later systemic treatment of psoriatic arthritis is started, the more disabling changes overtakes a person, dooming him to immobility, and in fact medicine today can push this “unwanted effect” for many years, or prevent it altogether!

DISPUTE MOMENTS OF GCS THERAPY clinical observation and opinion of a rheumatologist – “InfoMedPharmDialog”

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RHEUMATOID ARTHRITIS: DISPUTE MOMENTS OF GCS THERAPY clinical observation and opinion of a rheumatologist

RHEUMATOID ARTHRITIS: DISPUTE MOMENTS OF GCS THERAPY
clinical observation and opinion of a rheumatologist

Usually, as clinical observations, doctors present some rare, atypical cases that could surprise colleagues with an unusual course of the disease or non-standard and successful solution of therapeutic problems. The clinical observation that I will give below, on the contrary, rather belongs to the category of frequent, unfortunately, situations.

Meshkov Aleksey Dmitrievich N.I. Pirogov, Ph.D.

The patient developed rheumatoid arthritis (RA) at the age of 66 years. The disease debuted with episodes of swelling, pain in the small joints of the hands. Laboratory data at the time of onset of the disease are unknown. The patient was treated with non-steroidal anti-inflammatory drugs (NSAIDs), sulfasalazine at a dose of 2 g per day. Apparently, this therapy was insufficient, since the arthritis became permanent, morning stiffness joined. By this time (more than 1 year has passed since the onset of the disease) are the first known clinical and immunological indicators – increased ESR, CRP, high titers of rheumatoid factor and ACCP, which today allows us to confidently confirm the diagnosis of rheumatoid arthritis.

The treatment was prescribed according to current clinical guidelines – methotrexate at a dose of 10 mg per week and methylprednisolone 8 mg per day. But the logic of the therapeutic approach, chosen as a continuation of treatment, is not entirely clear. As expected, the patient improved fairly quickly on the recommended treatment. Twice attempts were made to reduce the dose of glucocorticosteroids (GCS), both times unsuccessfully – with a decrease in the dose, arthritis worsened. It is not known whether this was a consequence of the patient’s poor compliance (there are quite pronounced cognitive impairments) or it was a deliberate medical tactic, but there has never been an attempt to increase the dose of methotrexate.

After 2 years of glucocorticosteroid therapy, the patient suffers a compression fracture of the spine (L5), and therefore she goes to endocrinologists. Therapy with calcium, vitamin D3 preparations begins, denosumab is prescribed. Endocrinologists recommend that the patient consult a rheumatologist.

He gradually increases the dose of methotrexate to 25 mg per week. This allows you to abandon the use of GCS in a year. Despite short-term episodes of deterioration after each reduction in the dose of corticosteroids, the patient did not develop adrenal insufficiency, and the remission of arthritis was maintained. There were no more compression fractures during this time, and in general the prognosis in this case seems to be quite favorable.

Discussion

Treat to target

There is a fairly common opinion among patients that methotrexate and other cytostatics are “chemistry” and that this treatment will “destroy” the immune system or “destroy” internal organs. Sometimes it is very difficult to convince the patient at the reception, it takes time, effort, psychological stability and extensive knowledge. Not always the doctor has all these resources in abundance, and as a result, patients receive minimal (and therefore ineffective) doses of methotrexate or refuse to use it at all. In the future, there is no escalation of therapy and the requirements of the key strategy for the treatment of rheumatoid arthritis – treat to target – are not observed.

Another, no less dangerous situation lies in hormonal preparations (GCS). According to a British retrospective analysis, corticosteroids are prescribed to more than half of outpatients with RA. They are allowed at the start of therapy or an exacerbation of the disease (change of basic drugs), but with the proviso that most current clinical recommendations require their cancellation after 3 months of treatment, less often after 6. In my opinion, the main danger lies here – when prescribing GCS, doctors do not always warn patients about the need to cancel them. Or they warn, but patients do not adequately and attentively perceive this information. Moreover, if it was possible to achieve remission using a combination of hormonal drugs and methotrexate, it is easier, of course, to leave all treatment “as is” – increasing the dose of methotrexate, lowering the dose of hormones is associated with additional actions, the need to control tests, repeat visits to the doctor, which can be burdensome for the patient and sometimes even for the specialist.

On the part of patients, the situation is also ambiguous. As well as about methotrexate, most of the “beginning” patients have already read on the Internet, learned on the forums about the side effects of GCS, and this, of course, has many advantages. But at the onset of rheumatoid arthritis, the pain can be so severe that NSAIDs do not help, and then a tablet of methylprednisolone or prednisolone, even if “terrible”, but incredibly effective, for the first time bringing significant investment, begins to be considered by the patient as the only true and possible treatment. Feeling good, there are no side effects of treatment during the “honeymoon” of GCS therapy, why in this case should you see a doctor if nothing hurts?

Thus, we see that at the first (and most important) stages of the meeting between a rheumatologist and his patient, difficulties can arise on both sides, which, under unfavorable circumstances, can lead to patients taking corticosteroids for years with rheumatoid arthritis.

In the first months, this can really turn out to be a win-win solution that benefits both the patient and the doctor, which is why corticosteroids are present in modern clinical guidelines. But the main difficulty and trick, as I wrote above, is that in many patients who have started treatment with GCS, such therapy can continue for years. Ultimately, years later, and in some patients with comorbidities, even months, everything will turn out to the detriment of both the patient and the doctors who will have to cope with this already more difficult situation.

Conscious prescription – from short to lifelong use

A very important caveat – in this case we are talking about rheumatoid arthritis, as the most common and “classic” arthritis, and for the most part can be extrapolated to other arthritis. In the treatment of spondyloarthritis, especially with an isolated axial lesion, there is even less room for systemic corticosteroids. And it is fundamentally important to separate systemic diseases in this case, such as systemic lupus erythematosus, vasculitis, and some others, in which, despite the undoubted success in expanding steroid-sparing treatment regimens and a differential approach using the minimum required doses of corticosteroids, it is this group of drugs that remains key and in most cases allows you to save the organ or life of the patient and, as a rule, is prescribed for long-term use, sometimes for life.

In the case of a “conscious” appointment of GCS for systemic diseases, as a rule, both the doctor and the patient know that this is a necessary and only correct step, and discuss in advance all possible side effects and ways to minimize them. Understanding that this treatment will be long, allows you to immediately begin the prevention of complications. In fact, in accordance with modern schemes for the prevention or treatment of osteoporosis, when taking corticosteroids, in addition to vitamin D3 and calcium preparations, almost all patients should immediately be prescribed bisphosphonates. In those situations where the appointment of GCS is planned for a short time, as a rule, less attention is paid to the prevention of complications, and therefore uncontrolled further intake of GCS without medical supervision may be more destructive.

In the case of rheumatoid arthritis, the use of corticosteroids is unfavorable in two ways. The first is the well-known side effects of steroid therapy: osteoporosis with compression fractures, glycemic disturbances, cataracts, increased risk of cardiovascular events and infections. Secondly, the question remains whether the rate of radiological progression is the same when achieving remission only at the expense of basic anti-inflammatory drugs (DMARDs) or a combination of lower doses of DMARDs in combination with GCS. Although it has been shown that the addition of corticosteroids to the basic drugs (DMARDs) in the case of active RA can slow radiographic progression, direct comparisons of outcomes in achieving remission on DMARDs or DMARDs + GCS have not been conducted. Apparently, there will be no significant need for such studies: in addition to GCS, doctors now have a large number of drugs in their arsenal that reliably slow down the radiological progression of rheumatoid arthritis. These are standard synthetic drugs that can be used in combinations, genetically engineered biological drugs and a relatively new group – Janus kinase inhibitors. It is hard to imagine that none of this variety of drugs will not suit the patient.

Of course, there are limitations – it is rarely possible to completely stop corticosteroids in patients who have received them for decades, and sometimes therapy with corticosteroids is the only possible way to help patients with an active chronic infectious process. Also, GCS may be needed in case of systemic manifestations of RA. Of course, every doctor will be able to find cases in his practice when long-term treatment without GCS was impossible. But this is more the exception than the rule.

Own niche

I don’t want to give the impression that I am categorically against the GKS under the RA. These drugs have their own and very important area of ​​​​use, but, like so much in medicine, the ratio of benefits and harms depends on the nuances: dose, route of administration and, most importantly, the duration of therapy. Perhaps compliance also needs to be taken into account – in the case when the patient does not follow the doctor’s recommendations well, injection therapy is probably preferable, since it is impossible for the patient to continue it on his own. It may be necessary to persistently convey to patients that with this disease this is only a temporary measure and after 3 or maximum after 6 months GCS will definitely need to be canceled. On the other hand, the problems of access to specialized care and drugs are absolutely understandable, especially at the stage of transition to “second-line” therapy – genetically engineered and targeted synthetic drugs.

Of course, corticosteroids have a certain and well-deserved place in the treatment of rheumatoid arthritis, but it is important to minimize the time of their use and not consider remission against the background of their use as a good result. And it’s hard for me not to call those cases when it is possible to completely cancel GCS in patients with RA as small victories.

Literature

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