Evidence to support or guide glucocorticoid tapering in rheumatoid arthritis is lacking

摘要

Low-dose glucocorticoids (GCs) improve symptoms and physical function and reduce joint damage in rheumatoid arthritis (RA). Over a third of patients with RA are managed with long-term oral GC, defined as daily use for ≥3 months. Current RA management guidelines recommend tapering GCs to the lowest effective dose as quickly as possible to minimise risk of GC-associated side effects, such as infections, cardiovascular events and bone fractures. However, there is little evidence to guide clinicians attempting to taper GCs, leading to widely variable practice patterns. This is of particular importance for patients with established RA who are maintained on long-term GCs. Such patients have higher cumulative GC exposure and increased rates of cardiovascular disease, osteoporosis and insulin resistance relative to early patients with RA, yet may face disease flare, adrenal insufficiency or other withdrawal symptoms when GC tapering is attempted. We searched clinicaltrials.gov for all registered studies evaluating oral GC tapering in adult patients with RA since September 2008. We found 2300 studies of adult patients with RA, 151 of which included GCs, and we reviewed these studies. Of these, 80 were excluded as irrelevant due to observational design (n=42), non-oral GC administration (n=34) or other reasons (n=4). An additional 60 studies did not evaluate GC tapering. The remaining 11 studies are presented in table 1 13–17 along with five additional studies captured by a previously published systematic review on this subject covering the years 1972–2011.