What low‑dose systemic glucocorticoid regimen should be used as a short‑term bridge for a patient with active rheumatoid arthritis and an ulcerative colitis flare while initiating disease‑modifying therapy?

Glucocorticoid Bridging for Rheumatoid Arthritis with Concurrent Ulcerative Colitis

Initiate prednisone 10 mg daily orally as bridging therapy for up to 3 months while optimizing DMARD therapy, with careful monitoring for UC exacerbation and rapid taper once RA disease control is achieved. 1, 2

Rationale for Low-Dose Glucocorticoid Bridging

• Glucocorticoids are superior to NSAIDs for RA disease control because they reduce both symptoms and structural progression, whereas NSAIDs provide only symptomatic relief without modifying disease progression. 1, 2
• The American College of Rheumatology conditionally recommends bridging therapy with oral glucocorticoids (<3 months) during DMARD initiation or escalation for patients with high or moderate disease activity. 1
• Low-dose prednisone (10 mg/day) effectively relieves short-term signs and symptoms while retarding radiographic progression in RA. 1, 3

Specific Dosing Protocol

• Start prednisone 10 mg daily orally as the initial bridging dose—this provides adequate anti-inflammatory effect without excessive toxicity. 1, 2
• Initial doses ≤7.5 mg/day are discouraged as they provide insufficient anti-inflammatory effect in the acute setting. 1
• Higher initial doses (>30 mg/day) should be strongly avoided due to increased risk of adverse effects. 1

Critical Consideration: Ulcerative Colitis Risk

• NSAIDs must be avoided entirely in this patient because they can precipitate or worsen UC flares through direct mucosal injury and should not be used for RA disease control. 4, 1
• Glucocorticoids at 10 mg/day prednisone equivalent do not carry the same UC exacerbation risk as NSAIDs and are the preferred anti-inflammatory agent. 1
• The dual benefit of controlling both RA inflammation and potentially providing some UC benefit makes low-dose prednisone the optimal choice in this clinical scenario. 1

Tapering Strategy

• Taper to 5 mg/day by week 8 once RA symptoms improve and DMARD therapy takes effect. 1
• Reduce the dose to 10 mg/day within 4-8 weeks of achieving disease control, then taper by 1 mg every 2-4 weeks once below 10 mg/day. 5, 6
• If relapse occurs during taper, increase back to the pre-relapse dose and taper more slowly. 1
• Discontinue glucocorticoids entirely before 3 months to minimize cumulative toxicity including osteoporosis, cardiovascular disease, and infections. 4, 2

Concomitant DMARD Optimization

• Ensure methotrexate is optimized to 20-25 mg weekly (oral or subcutaneous route preferred) before declaring treatment failure. 2
• Continue current DMARD regimen unchanged while initiating prednisone bridging therapy. 1
• If inadequate response persists after 3 months despite optimized methotrexate and prednisone taper, escalate to combination DMARDs or biologic therapy. 1, 2

Essential Monitoring and Prophylaxis

• All patients receiving glucocorticoids with concurrent UC should receive proton pump inhibitor therapy for GI prophylaxis, as the combination significantly increases gastrointestinal bleeding risk. 4, 1
• If prednisone continues >3 months at >7.5 mg daily, prescribe calcium and vitamin D supplementation to reduce glucocorticoid-induced osteoporosis risk. 4
• Monitor blood pressure, blood glucose, body weight, and peripheral edema at each visit during glucocorticoid therapy. 4

Treatment Algorithm by Disease Activity Response

• Assess RA disease activity at 3 months using validated measures (SDAI, CDAI, or DAS28). 2
• If patient has not achieved low to moderate disease activity despite optimized methotrexate (20-25 mg/week) and prednisone tapered to 5 mg/day by week 8, escalate therapy immediately with combination DMARDs or biologic agents. 1, 2
• If SDAI ≥26 or CDAI ≥22 at 3 months despite optimized therapy, add biologic response modifiers immediately rather than continuing ineffective treatment. 1

Critical Pitfalls to Avoid

• Do not use NSAIDs (including COX-2 inhibitors) in this patient due to UC—reserve glucocorticoids as the sole anti-inflammatory agent. 4, 1
• Do not continue prednisone beyond 3 months at doses >10 mg/day due to cumulative toxicity including infections, cardiovascular events, and osteoporosis. 4, 2
• Do not continue ineffective therapy beyond 3 months hoping for delayed response, as this allows irreversible joint damage to progress. 2
• Avoid abrupt discontinuation after prolonged use (>1 month), as this risks adrenal insufficiency—taper gradually. 4, 5

Alternative Approach for Localized Joint Involvement

• If only 1-2 joints are affected (such as isolated wrist involvement), consider intra-articular glucocorticoid injection with triamcinolone hexacetonide as an adjunct for relief of local symptoms. 4, 1
• This approach minimizes systemic glucocorticoid exposure while providing effective local disease control. 4