What is the recommended oral corticosteroid (CS) dose and duration of treatment for arthritis, specifically rheumatoid arthritis (RA)?

Oral Corticosteroid Dosing for Rheumatoid Arthritis

For rheumatoid arthritis, the recommended oral corticosteroid dose is 12.5-25 mg prednisone daily for short-term use (less than 3 months), with tapering as rapidly as clinically feasible. 1, 2

Initial Dosing Recommendations

• Initial prednisone dose should be within the range of 12.5-25 mg daily, with the specific dose determined by the patient's risk profile 2
• Higher initial doses within this range (closer to 25 mg) are appropriate for patients with high risk of relapse and low risk of adverse events 2
• Lower initial doses (closer to 12.5 mg) should be used for patients with relevant comorbidities such as diabetes, osteoporosis, or glaucoma 2
• Initial doses ≤7.5 mg/day are discouraged and doses >30 mg/day are strongly recommended against 1, 2
• Short-term glucocorticoids should be considered when initiating or changing conventional synthetic DMARDs (csDMARDs) 1

Tapering Schedule

• After achieving symptom control, reduce the dose gradually to 10 mg/day within 4-8 weeks 2
• Once remission is maintained, taper prednisone by 1 mg every 4 weeks (or similar, e.g., 2.5 mg/10 weeks) until discontinuation 1, 2
• Glucocorticoids should be tapered as rapidly as clinically feasible, usually within 3 months from treatment start and only exceptionally by 6 months 1
• Long-term use of glucocorticoids, especially at doses above 5 mg/day, should be avoided because of potential risks 1

Duration of Treatment

• The 2021 American College of Rheumatology guideline strongly recommends initiation of a csDMARD without longer-term (≥3 months) glucocorticoids over initiation of a csDMARD with longer-term glucocorticoids 1
• Short-term glucocorticoid use (<3 months) is conditionally recommended when starting csDMARDs 1

Special Considerations

• For persistent nighttime pain when tapering below 5 mg/day, consider splitting the daily dose rather than using a single morning dose 1
• If insufficient improvement occurs within 2 weeks, consider increasing the oral dose up to 25 mg prednisone 2
• For patients who relapse while on treatment, increase prednisone to the pre-relapse dose and then decrease gradually to the dose at which relapse occurred 2

Alternative Approaches

• Intramuscular methylprednisolone (120 mg every 3 weeks) can be considered as an alternative to oral glucocorticoids in select patients 1, 2
• For patients with frequent relapses or prolonged therapy needs, consider adding methotrexate (7.5-10 mg weekly) as a corticosteroid-sparing agent 1, 2

Monitoring and Follow-up

• Follow patients every 4-8 weeks during the first year of treatment 2
• Monitor inflammatory markers and clinical symptoms to assess treatment response 2
• Systematically evaluate for corticosteroid-related adverse effects, particularly bone mineral density 2
• Consider calcium (800-1,000 mg/day) and vitamin D (400-800 units/day) supplementation to prevent bone loss 3

Evidence on Long-term Low-dose Use

• Some observational data suggests that many patients with RA might be treated effectively with initial and long-term prednisone <5 mg/day 4
• The mean initial prednisone dose in clinical practice has declined from 10.3 mg/day in 1980-1984 to 3.6 mg/day in 2000-2004 4
• Primary adverse events with long-term low-dose use (<5 mg/day) are skin thinning and bruising, with new hypertension, diabetes mellitus, and cataracts occurring in <10% of patients treated for more than 8 years 4

Caution

• Rebound deterioration may occur after tapering prednisone, particularly if done too rapidly 5
• Evidence for increased overall and cardiovascular mortality exists at doses above a threshold of 7.5 mg/day or a cumulative dose of 40 g 1