In adult patients with rheumatoid arthritis, what is the recommended role, dosing, duration, and monitoring of glucocorticoids (e.g., prednisone) as adjunct therapy, including contraindications and use of intra‑articular injections?

Role of Glucocorticoids in Rheumatoid Arthritis Management

Glucocorticoids should be used as temporary adjunctive therapy in rheumatoid arthritis—initiated at 7.5-10 mg/day prednisone equivalent alongside DMARDs for rapid symptom control and erosion prevention, then tapered to discontinuation within 3 months as DMARD therapy takes effect. 1, 2

Primary Therapeutic Role

Glucocorticoids serve three distinct functions in RA management, each with specific indications:

1. Bridging Therapy (Preferred Use)

• Initiate prednisone 7.5-10 mg/day when starting or escalating DMARD therapy in patients with moderate-to-high disease activity 2, 3
• This approach provides rapid symptom relief within days while DMARDs require 6-12 weeks to achieve therapeutic effect 2, 4
• Glucocorticoids reduce both pain/swelling AND structural progression—effects that NSAIDs cannot achieve 2, 1
• Duration must be limited to <3 months to minimize cumulative toxicity 1, 2

2. Intra-Articular Injections for Localized Disease

• Triamcinolone hexacetonide is strongly preferred over triamcinolone acetonide for intra-articular injections 1, 5
• Use for mono/oligoarticular involvement (1-4 joints) or single joint flares in otherwise controlled polyarthritis 1
• Limit to approximately one injection per joint every 6 weeks, maximum 3-4 injections per year 5
• Employ strict aseptic technique; consider ultrasound guidance for accuracy 5

3. Chronic Low-Dose Therapy (Controversial—Generally NOT Recommended)

• Current ACR guidelines conditionally recommend AGAINST chronic glucocorticoid use 1
• If DMARDs fail to control disease after optimization, add/switch DMARDs rather than continuing glucocorticoids 1
• The exception: some patients may require maintenance at 5 mg/day if they cannot achieve control despite maximized DMARD therapy 2, 3

Specific Dosing Protocols

Initial Dosing Strategy

• Start at 7.5-10 mg/day prednisone equivalent 2, 3
• Doses ≤7.5 mg/day provide insufficient anti-inflammatory effect in acute settings 2
• Doses >30 mg/day should be strongly avoided due to markedly increased adverse event risk 2
• For severe polyarthritis, may initiate at 0.5-1 mg/kg daily (30-60 mg for average adult), then taper rapidly 3

Tapering Protocol

• Reduce to 10 mg/day within 4-8 weeks 2
• Then taper by 1 mg every 4 weeks until reaching 5 mg/day by week 8 2, 3
• Discontinue entirely by 3 months 1, 2
• If relapse occurs during taper, increase back to pre-relapse dose and taper more slowly 2
• Avoid abrupt cessation after >1 month of use—gradual taper prevents adrenal insufficiency 2

Alternative Routes

• Intramuscular methylprednisolone 120 mg every 3 weeks can be considered for patients requiring lower cumulative exposure or unable to tolerate oral therapy, though long-term benefit is unknown 1, 3

Contraindications and Precautions

Absolute Contraindications

• Active systemic infection (relative—may use with appropriate antimicrobial coverage)
• Live vaccine administration planned (glucocorticoids ≥20 mg/day for ≥2 weeks cause significant immunosuppression) 2

Relative Contraindications Requiring Dose Adjustment

• Diabetes mellitus: Use lower end of dosing range (7.5 mg/day) and monitor glucose closely 2, 3
• Cardiovascular disease: Minimize dose and duration due to increased hypertension/fluid retention risk 2
• Osteoporosis or prior fragility fracture: Use lowest effective dose with mandatory bone protection 2, 3
• Peptic ulcer disease or GI bleeding history: Require PPI prophylaxis 2
• Recurrent infections: Consider alternative strategies or enhanced monitoring 2

Special Population: Ulcerative Colitis

• NSAIDs must be completely avoided in RA patients with concurrent ulcerative colitis as they precipitate UC flares 2
• Glucocorticoids become the preferred anti-inflammatory agent in this population 2

Mandatory Monitoring and Prophylaxis

Pre-Treatment Assessment

• Screen for hypertension, diabetes, peptic ulcer disease, recent fractures, cataracts, glaucoma, and chronic infections 2
• Screen for latent tuberculosis before initiating therapy, especially if planning biologic DMARDs 3

During Treatment Monitoring (Every Visit)

• Blood pressure, blood glucose, body weight, and peripheral edema 2
• Serum lipids periodically 2
• Bone mineral density if treatment >3 months at >7.5 mg/day 2
• Ophthalmologic examination for cataracts/glaucoma (annually if prolonged use) 2

Required Prophylaxis

• Calcium 800-1000 mg/day plus vitamin D 400-800 units/day for ALL patients on glucocorticoids 2, 6
• Proton pump inhibitor for GI prophylaxis, especially when combined with NSAIDs 2
• Consider bisphosphonate therapy when bone mineral density is low or fracture risk is high 2
• PCP prophylaxis for patients receiving ≥20 mg prednisone for ≥12 weeks or high-dose (>20 mg) for ≥4 weeks 3

Integration with DMARD Therapy

Critical Principle: Glucocorticoids Are NOT Monotherapy

• Methotrexate is the anchor DMARD and must be initiated/optimized concurrently 1, 2
• Start methotrexate at 15 mg weekly with folic acid 1 mg daily 2
• Escalate methotrexate by 5 mg monthly to reach 20-25 mg weekly within 2-3 months 2
• If inadequate response at 20-25 mg oral methotrexate, switch to subcutaneous administration 2

Treatment Algorithm by Disease Activity at 3 Months

• If not achieving low disease activity despite optimized methotrexate (20-25 mg/week) and prednisone tapered to 5 mg/day, escalate to combination DMARDs or biologic agents 2
• If SDAI ≥26 or CDAI ≥22 at 3 months, add combination therapy or biologics immediately 2

Common Pitfalls and How to Avoid Them

Pitfall 1: Using Glucocorticoids Instead of DMARDs

• Never use glucocorticoids as monotherapy or delay DMARD initiation 1, 2
• Glucocorticoids are bridging agents only—DMARDs provide definitive disease control 1

Pitfall 2: Continuing Beyond 3 Months

• Doses >10 mg/day beyond 3 months markedly increase risk of fractures, infections, and GI bleeding 2
• If unable to taper, the problem is inadequate DMARD therapy, not insufficient glucocorticoid dose 1, 2

Pitfall 3: Combining with NSAIDs Without Gastroprotection

• Glucocorticoids plus NSAIDs significantly increase GI bleeding risk compared to either alone 2
• Always provide PPI prophylaxis if combination is necessary 2
• Glucocorticoids should replace NSAIDs for disease control, not supplement them 2

Pitfall 4: Inadequate Bone Protection

• All patients require calcium and vitamin D supplementation from day one 2, 6
• Failure to provide bone protection is the primary cause of glucocorticoid-induced osteoporosis 2

Pitfall 5: Abrupt Discontinuation

• Patients on >7.5 mg/day for >3 weeks have HPA axis suppression and require stress dosing for acute illness/surgery 2
• Gradual taper over 4-8 weeks prevents adrenal crisis 2

Pitfall 6: Ignoring Perioperative Management

• For patients on chronic glucocorticoids undergoing elective surgery, continue current daily dose rather than "stress dosing" 1, 5
• This applies to doses ≤16 mg/day prednisone equivalent 1

Glucocorticoids vs. NSAIDs: The Evidence

Glucocorticoids are superior to NSAIDs for RA disease control and should be prioritized 2:

• Glucocorticoids reduce symptoms AND structural progression 1, 2
• NSAIDs provide only symptomatic relief without disease modification 1, 2
• Reserve NSAIDs only for short-term pain relief from non-RA conditions 2
• NSAIDs must be evaluated for GI, renal, and cardiovascular risk before use 1

Disease Activity Assessment Schedule

• Monitor disease activity every 1-3 months until remission achieved 1
• Assess tender/swollen joint count, patient/physician global assessment, ESR, and CRP 1
• Obtain radiographs of hands/feet every 6-12 months during first few years 1
• Functional assessment (HAQ) complements disease activity monitoring 1