Can glucocorticoids be used as long‑term maintenance therapy for rheumatoid arthritis?

Glucocorticoids for Long-Term Maintenance in Rheumatoid Arthritis

Glucocorticoids should not be used as long-term maintenance therapy for rheumatoid arthritis; they should be tapered to the lowest effective dose and discontinued as soon as disease control is achieved with disease-modifying antirheumatic drugs (DMARDs). 1

Guideline-Based Recommendations

For prolonged treatment, glucocorticoid dosage must be kept to a minimum, and a taper should be attempted in cases of remission or low disease activity; the reasons to continue glucocorticoid therapy should be regularly checked. 1 This EULAR recommendation explicitly states that long-term glucocorticoid use requires ongoing justification and active attempts at discontinuation.

Acceptable Short-Term Use

• Glucocorticoids are appropriate as bridging therapy in early RA while waiting for DMARDs to take effect, but this is explicitly time-limited. 2, 3
• When glucocorticoids are used for more than 3 months at doses >7.5 mg prednisone daily, calcium and vitamin D supplementation is mandatory, and bisphosphonate therapy should be considered based on fracture risk and bone mineral density. 1

Why Long-Term Maintenance Is Not Recommended

• Biologic or conventional synthetic DMARDs are strongly recommended over long-term glucocorticoids for persistent arthritis in inflammatory joint diseases. 1
• The American College of Rheumatology guidelines for juvenile idiopathic arthritis (which share pathophysiology with adult RA) explicitly state that longer-term glucocorticoid therapy is not appropriate because of effects on bone health and growth, and this principle extends to adults with additional concerns about cardiovascular disease, diabetes, and infections. 1

Adverse Effects That Accumulate Over Time

The EULAR systematic review documented adverse events per 100 patient-years at a mean daily dose of only 8 mg prednisone over 19.6 months: 1

• Infections: 15 events per 100 patient-years
• Gastrointestinal complications (peptic ulcer, pancreatitis): 10 per 100 patient-years
• Psychological/behavioral effects: 9 per 100 patient-years
• Endocrine/metabolic complications (diabetes, fat redistribution): 7 per 100 patient-years
• Musculoskeletal effects (osteoporosis, osteonecrosis, myopathy): 4 per 100 patient-years
• Ophthalmologic complications (glaucoma, cataract): 4 per 100 patient-years

These risks accumulate with duration of exposure, making indefinite maintenance therapy untenable from a morbidity and quality-of-life standpoint. 4

Practical Management Algorithm

Step 1: Initial Disease Control

• Start prednisone ≤7.5 mg daily (or equivalent) plus a conventional synthetic DMARD (typically methotrexate) at RA diagnosis. 2, 3
• Higher initial doses may be used for severe flares but should be rapidly tapered within weeks. 5

Step 2: DMARD Optimization (Weeks 4–12)

• Escalate DMARD therapy aggressively if disease activity persists—add a second conventional synthetic DMARD or switch to a biologic DMARD. 3, 5
• Do not maintain glucocorticoids at the initial dose while waiting for DMARD effect beyond 12 weeks. 1

Step 3: Glucocorticoid Taper (Months 3–6)

• Once disease activity is controlled (low disease activity or remission), begin tapering prednisone by 1–2.5 mg every 2–4 weeks. 2, 3
• Target complete discontinuation by 6 months if DMARDs are providing adequate disease control. 1

Step 4: If Taper Fails

• If disease flares during taper, do not resume long-term glucocorticoids—instead, intensify DMARD therapy by adding or switching to a biologic agent (TNF inhibitor, IL-6 inhibitor, JAK inhibitor, or abatacept). 1, 5
• Short-term glucocorticoid "rescue" (2–4 weeks) may be used during DMARD transitions, but this is not maintenance therapy. 3

Monitoring Requirements for Any Glucocorticoid Use

Before starting glucocorticoids, evaluate and treat: 1

• Hypertension
• Diabetes or glucose intolerance
• Peptic ulcer disease
• Osteoporosis risk (fracture history, bone density)
• Cataract or glaucoma
• Chronic infections
• Dyslipidemia

During treatment, monitor: 1

• Body weight and blood pressure at every visit
• Fasting glucose or HbA1c every 3–6 months
• Lipid panel annually
• Ophthalmologic examination annually if dose >7.5 mg or duration >3 months

Common Pitfalls to Avoid

• Do not continue glucocorticoids indefinitely "because the patient feels better"—this reflects inadequate DMARD therapy, not a need for chronic steroids. 1, 3
• Do not use "low-dose" prednisone (5 mg daily) as a substitute for optimizing DMARDs—even low doses cause cumulative toxicity, and recent observational data suggesting favorable risk-benefit ratios 2 do not override guideline recommendations prioritizing DMARD monotherapy or combination therapy over any chronic glucocorticoid use. 1
• Do not rely on patient preference for glucocorticoids over DMARDs—the adverse effects of glucocorticoids (discussed above) must be weighed against the proven disease-modifying effects and superior long-term safety of biologic and conventional synthetic DMARDs. 1, 4, 5
• Do not forget gastro-protection—patients on glucocorticoids plus NSAIDs require proton pump inhibitors or misoprostol, or should switch to a COX-2 selective inhibitor. 1

Nuance: The "Bridging" vs. "Maintenance" Distinction

Recent literature 2, 3 discusses prolonged low-dose glucocorticoid use in selected patients, but this reflects real-world practice patterns rather than guideline-endorsed strategy. The EULAR and ACR guidelines are unambiguous: glucocorticoids are bridging agents, not maintenance therapy. 1 When disease activity cannot be controlled without chronic glucocorticoids, the solution is to escalate DMARD therapy (add methotrexate, switch to or add a biologic), not to accept indefinite steroid dependence. 1, 5