Corticosteroids / Prednisone – Medications for Rheumatoid Arthritis (RA)

Corticosteroids like prednisone have powerful anti-inflammatory effects.  In the 1950s, when they were first introduced as a treatment for Rheumatoid Arthritis (RA) they were hailed as ‘a cure’.  Unfortunately this conclusion was seriously premature, as it became very apparent, very quickly, that prednisone causes serious adverse events and side effects, especially with prolonged use and/or high dosages.

Corticosteroids are usually given orally, however they can also be injected directly into the joint.

The current thinking on prednisone use is to use the lowest dose that provides symptomatic relief, for the shortest possible time.  Having said this, in some cases of severe rheumatoid arthritis, some patients still require long term therapy and/or high dose therapy to achieve any kind of relief. Each patient must be assessed individually to weight the potential side effects against the benefits.

How does prednisone work?

Corticosteroids have a wide range of biological activities including anti-inflammatory and immunosuppressive effects, which is why they are so useful in Rheumatoid Arthritis.  Because prednisone weakens the immune system, however, it can make it easier for the patient to get an infection or worsen an existing infection.  When taking prednisone, patients should take care to avoid being near people who are sick.

Prednisone dose

From Australian Prescriber “In patients who cannot tolerate NSAIDs or in whom the use of DMARDs has proven to be problematic, e.g. adverse effects, monitoring difficulties or poor compliance, the use of a low-dose corticosteroid e.g. prednisolone 5-10 mg/day, may provide good control of symptoms and improved function.” It’s common to start patients with moderate to severe Rheumatoid Arthritis on a higher dose – 20 – 25mg per day to get symptoms under control initially and improve pain levels and ability to function.  This dose is gradually tapered down to reach the lowest dose that will control symptoms. After a week of treatment, prednisone will interfere with the body’s ability to produce corticosteroids (especially cortisol), so the drug cannot be stopped suddenly.  Corticosteroids/prednisone need to be tapered down very gradually to allow the body’s own ability to manufacture cortisol to recover.  The tapering may be quick (over the course of days) if the treatment was short, but will be much slower if treatment was long term.

Prednisone side effects

Short term side effects include high blood glucose levels, especially in diabetic patients.  Common short term side effects are headache, insomnia, increased appetite, euphoria, and rarely , mania (particularly in patients with Bipolar Disorder.  Prednisone has been known to induce a patient’s first bipolar episode)  It can also cause anxiety, and depression, especially when tapering off. Long term side effects include Cushings syndrome,  weight gain especially around the mid riff and face, osteoporosis, glaucoma and cataracts, type II diabetes mellitus and major depression.  Prednisone also lowers the body’s ability to heal, and can also cause avascular necrosis (bone death).

Contraindications

If the patient has a current infection, prednisone will worsen this, and therefore should not be prescribed.  Patients with diabetes mellitus may not be able to take prednisone.  Patients with bi-polar disorder should not take prednisone.

Pregnancy/Breastfeeding

Prednisone may be used in pregnancy, but each case is individual and needs and risks to the fetus vs benefits need to be weighed up. Prednisone does pass into breast milk in small quantities.