A new trial shows a vast majority of patients can get off steroids permanently when used at diagnosis.
Most patients with newly diagnosed rheumatoid arthritis can successfully stop prednisolone after a short period of time as a way of bridging to the start of methotrexate therapy, according to new data that strengthen European recommendations for limited steroid use in early disease.
Researchers analysing the ARCTIC trial found more than 80% of patients discontinued prednisolone after a seven-week taper, with nearly nine in 10 stopping within three months.
Only 5% of patients remained on oral glucocorticoids throughout the two-year follow-up, suggesting fears of prolonged steroid dependence after bridging therapy may be overstated when treatment follows a strict treat-to-target protocol.
The findings have been published in the Annals of the Rheumatic Diseases and come amid ongoing debate about glucocorticoids in early rheumatoid arthritis.
“Challenges in the balancing of benefits and harms of glucocorticoid bridging, in combination with limited evidence, have led to different international approaches to the topic,” the researchers wrote.
“The latest European Alliance of Associations for Rheumatology (EULAR) recommendations suggest using low-dose glucocorticoids when starting conventional synthetic (cs)DMARDs, with tapering and discontinuing of glucocorticoids as rapidly as clinically feasible, ideally within three months.
“In contrast, the 2021 American College of Rheumatology (ACR) guidelines advise avoiding the use of glucocorticoids altogether.
“The ACR recommendations highlight concerns about glucocorticoid toxicity and the presumed challenge in tapering glucocorticoids once started, and can lead to undesirably prolonged glucocorticoid use, potentially outweighing the known benefits.
“There is currently no evidence for the optimal dose and duration of glucocorticoid bridging therapy. Data on discontinuation of glucocorticoids after the initial bridging therapy are scarce, especially with lower cumulative glucocorticoid doses, as suggested by current recommendations.”
In the Norwegian-led ARCTIC study, 227 DMARD-naive patients with recent-onset RA started methotrexate and a predefined prednisolone taper beginning at 15mg daily and stepping down to zero over seven weeks.
The cohort had a mean age of 52 years, 62% were women and more than 80% were ACPA-positive.
At the end of the tapering period, 84% had successfully stopped prednisolone and remained off it for at least four months. By three months this figure had climbed to 89%, with 95% of patients discontinuing the treatment after two years.
Among those who stopped at seven weeks, 80% never needed to restart prednisolone during follow-up.
Overall steroid exposure was relatively modest. The median duration of prednisolone use across the entire two-year period was 55 days, and the median cumulative oral dose was 332.5mg.
A minority of patients received intra-articular steroid injections for flares, mostly early in the treatment course.
About one in five patients used prednisolone continuously for three months or longer. These patients appeared to have a more difficult disease course, requiring more treatment adjustments, greater use of biologic DMARDs and achieving lower remission rates at two years compared with those who discontinued steroids early.
Investigators found no clear baseline predictors of who would successfully stop prednisolone after the bridging period, although higher disease activity scores showed a weak association with ongoing steroid use.
More than half of the total cohort met Boolean remission criteria at two years, with remission rates significantly higher in patients who did not restart prednisolone after the initial taper.
The researchers highlighted one notable limitation of our study as the absence of a control group without bridging therapy or with a different tapering regimen.
“Additionally, there is a possibility that some patients may have resumed prednisolone use outside the study without notifying the study personnel,” they wrote.
“However, this is considered relatively unlikely due to the close follow-up. Furthermore, a key strength of our study is the rigorous follow-up and detailed recording of prednisolone use.”
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The researchers said the results supported the feasibility of short-term glucocorticoid bridging when combined with tight disease control and rapid DMARD escalation.
“Although further research is necessary to determine predictors of unsuccessful tapering, short-term prednisolone bridging therapy appears effective for most patients with RA, with over 80% able to discontinue treatment after seven weeks,” they concluded.
“However, translating this approach into routine care, where visits are less frequent, targets less clearly defined, and patients often have more comorbidities, requires adaptation.
“Implementing standardised tapering protocols, proactive DMARD escalation, patient education, and systematic monitoring could help replicate trial success and minimise long-term harm.
“These findings support current EULAR recommendations and emphasise the advantages of lower glucocorticoid doses combined with a systematic follow-up.”
