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Low-dose steroids are neither safe nor effective for long-term treatment of rheumatoid arthritis

Doctors should abandon the use of low-dose glucocorticoids such as prednisone as an antiquated approach to the treatment of rheumatoid arthritis (RA) in favor of more targeted and safer RA treatments, recommends Kenneth G. Saag, M.D., M.Sc., in a recent commentary. He contends that long-term low-dose glucocorticoids, a type of steroid, simply do not work (their antiinflammatory benefits decline considerably after the first year), and they can cause undue adverse effects and toxicity. High on the list of problems is the dramatic bone loss and resulting fracture risk from prolonged glucocorticoid use. Yet few RA patients are being evaluated and treated for this potential complication.

One study estimated that more than half of glucocorticoid users develop bone loss leading to fracture. Other studies have suggested a mean first-year loss of bone of up to 15 percent at the dose range of 10 mg per day or less of prednisone and up to a loss of 3 percent per year in subsequent years. Another study found that 34 percent of women on a mean dose of prednisone of 8.6 mg per day had suffered a fracture within 5 years of followup.

Cataract is another well-described complication of prolonged glucocorticoid use. Cataract may develop even when inhaled glucocorticoids are used. In addition, increased intraocular pressure may develop in these patients, increasing the risk of glaucoma.

Long-term use of low-dose glucocorticoids also may lead to development of premature atherosclerosis. One study found a three-fold increase in atherosclerosis in RA patients treated with glucocorticoids compared with nonsteroid-treated patients. Biologic response-modifying drugs are now available to treat RA, such as methotrexate, leflunomide, etanercept, and infliximab. When the serious problems associated with glucocorticoids are adequately explained, patients' perceptions of and preference for their use may change markedly, says Dr. Saag. His work at the Center for Education and Research on Therapeutics of Musculoskeletal Disorders, University of Alabama at Birmingham, is supported in part by the Agency for Healthcare Research and Quality (HS10389).

More details are in "Resolved: Low-dose glucocorticoids are neither safe nor effective for the long-term treatment of rheumatoid arthritis," by Dr. Saag, in the October 2001 Arthritis Care & Research 45, pp. 468-471.

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