What is the preferred choice between prednisone (corticosteroid) and meloxicam (nonsteroidal anti-inflammatory drug, NSAID) for bridging therapy in rheumatoid arthritis?

Prednisone vs Meloxicam for Bridging Therapy in Rheumatoid Arthritis

Prednisone is strongly recommended over meloxicam for bridging therapy in rheumatoid arthritis. Glucocorticoids should be used instead of NSAIDs for disease control, with NSAIDs reserved only for short-term symptomatic relief of pain related to other conditions. 1

Rationale for Prednisone as Bridging Therapy

Bridging therapy with a limited course of oral glucocorticoid (<3 months) during initiation or escalation of DMARD therapy is conditionally recommended for patients with high or moderate disease activity. 1 This approach is particularly useful when rapid disease control is needed while waiting for DMARDs to take effect.

Optimal Prednisone Dosing for Bridging

• Initial dose: 10 mg/day prednisone is the standard low-dose glucocorticoid regimen for RA bridging therapy 2, 3, 4
• Duration should be less than 3 months to minimize adverse effects while providing rapid symptom relief 1, 3
• Doses ≤7.5 mg/day are discouraged as they provide insufficient anti-inflammatory effect 2
• Doses >30 mg/day should be strongly avoided due to increased adverse effect risk 2

Evidence Supporting Prednisone Over NSAIDs

The evidence strongly favors glucocorticoids over NSAIDs for disease control:

• Meta-analysis data demonstrates prednisone's superiority: Low-dose prednisolone (≤15 mg daily) showed marked superiority over placebo with standardized effect sizes of 1.31 for joint tenderness and 1.75 for pain, translating to 12 fewer tender joints 4
• Prednisone also outperformed NSAIDs directly: Compared to NSAIDs, prednisolone showed superior effects on joint tenderness (effect size 0.63) and pain (effect size 1.25), with 9 fewer tender joints 4
• Structural benefit: Glucocorticoids reduce both symptoms AND structural progression, whereas NSAIDs provide only symptomatic relief 1

Why Not Meloxicam for Bridging?

NSAIDs including meloxicam have significant limitations for bridging therapy:

• NSAIDs are effective only as symptomatic therapy and do not modify disease progression 1
• NSAIDs should be used at minimum effective dose for shortest time possible after careful evaluation of gastrointestinal, renal, and cardiovascular risks 1
• While meloxicam showed good long-term safety in RA patients over 18 months, it functions purely as symptomatic treatment without the disease-modifying effects seen with glucocorticoids 5
• Guidelines explicitly recommend glucocorticoids instead of NSAIDs for disease control in inflammatory arthritis 1

Clinical Implementation Algorithm

For patients starting or escalating DMARD therapy:

1. Assess disease activity level 1

   • High/moderate disease activity → Initiate prednisone bridging
   • Low disease activity → Consider intra-articular glucocorticoid injections instead 1

2. Initiate prednisone 10 mg/day 2, 3, 6

   • Continue for maximum 12 weeks while DMARD takes effect 6

3. Taper gradually after 12 weeks 6

   • Week 13-14: 7.5 mg/day
   • Week 15-16: 5 mg/day
   • Week 17-18: 2.5 mg/day
   • Then discontinue

4. Monitor for rebound flare after tapering, which occurs in approximately 58% of responders 6

Critical Caveats

• Avoid chronic low-dose glucocorticoid use beyond the bridging period, as long-term use should be avoided despite short-term benefits 7
• Monitor for adverse effects: bone mineral density, blood pressure, blood glucose, and ocular examinations are essential 2
• Bridging therapy may be most useful when patients have limited mobility and/or significant symptoms requiring rapid control 1
• Rebound deterioration is common: 58% of responders experience disease flare after tapering, emphasizing the need for adequate DMARD therapy to be established during the bridging period 6