Glucocorticoids in rheumatoid arthritis: the silent companion in the therapeutic strategy

ABSTRACT

Introduction

Glucocorticoids (GCs) are key actors in RA management, despite the increasing number of available drugs. In fact, due to their efficacy and safety, the combination therapy between GCs and conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) is still recommended in the early phase of RA treatment, because improving the long-term results.

Areas covered

In this paper, we reviewed the role of GCs in RA management, focusing on mechanisms of action as well as the benefit/risk ratio of GCs and newer therapeutic formulations. Furthermore, we analyzed GCs DMARDs proprieties on disease activity and their long-term effects on radiographic damage. We designed a narrative review aimed to provide an overview concerning GCs in RA management.

Expert opinion

A large amount of evidence supports the use of GCs in RA, especially in the earliest phases of the disease. Besides GCs symptomatic effects due to their strong anti-inflammatory effects, data from several randomized clinical trials have shown a substantial benefit of low-dose GCs in inhibiting the radiographic damage, thus highlighting GCs DMARDs properties. Besides their recognized role in the treatment of early RA, systematic monitoring of adverse events should be recommended to minimize GCs toxicity.

KEYWORDS:

• Adverse events
• corticosteroids
• drug efficacy
• glucocorticoids
• rheumatoid arthritis
• therapies

Acknowledgments

The authors thank Mrs Federica Sensini for her technical assistance.

Article highlights

• Available recommendations suggest the combination therapy between GCs and conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) in the initial treatment in RA.

• The GCs exert both anti-inflammatory and immunosuppressive effects via different mechanisms of action: genomic effects via cytosolic GC receptors (cGCRs); non-genomic effects cGCR-mediated; non-genomic effects via membrane-bound GCRs (mGCRs); non-specific, non-genomic effects.

• In RA GCs have a rapid onset of action due to their strong anti-inflammatory effects on the symptoms, and, after that, there can modify the disease course, due to their immunosuppressive activity.

• In RA patients, the incidence of myocardial infarction, heart failure, and cerebrovascular accidents, was not increased in patients using a low GCs dosage (≤7.5 mg equivalent prednisone/day).

• Effective and adequate suppression of inflammation in RA patients could help in reducing the direct negative effect of GC therapy.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewers declaration

A reviewer on this manuscript has disclosed received consulting fees, speaking fees, and honoraria from Astellas, Abbvie, Ayumi, Asahi Kasei, BMS, Eisai, Eli Lilly, Pfizer, Daiichi-Sankyo, Janssen, Mitsubishi Tanabe, Chugai, Novartis, Nihon Kayaku, and UCB. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.