Rheumatoid arthritis (RA) is a systemic, chronic, progressive, autoimmune disorder that affects, roughly, two million Americans. While it preferentially attacks joints, it may affect other organ systems. These other areas include the lungs, heart, peripheral nervous system, skin, bone marrow, and eyes.
Early diagnosis is mandatory. If RA is suspected, a patient should be referred to a rheumatologist (arthritis specialist) as soon as possible. The current goal of RA therapy is to treat and control disease before any joint damage has occurred. The prognosis, both short as well as long term is improved if remission can be established quickly.
The strategy is to exert tight control over the disease while recognizing individual variability and response to treatment. A new concept of "treat to target" has gained popularity. What this means is following a patient carefully early on and making adjustments in medicines in order to effect a remission as soon as possible.
The role of disease modifying anti-rheumatic drugs (DMARD) therapy is not in question. And the DMARD of choice is methotrexate which works relatively quickly, slows don progression of disease and is usually tolerated well.
However, there is debate when it comes to other therapies.
One such therapy is prednisone (P). P is an oral glucocorticoid, a synthetic drug that mimics the effects of naturally occurring hormones made by the adrenal glands. These medications have potent anti-inflammatory effects. A number of studies have shown that low doses of P (less than 10 mgs a day) reduces joint damage and slows down the progression of x-ray changes.
At our center, we rarely use disease higher than 5 mgs in RA patients. However, we do institute this low dose of P along with methotrexate as soon as the diagnosis is made. Adhering to the "treat to target" model, we also rapidly introduce a biologic therapy within 8-12 weeks if it appears that methotrexate is not going to be sufficient. Unlike other centers, we rarely push the methotrexate any higher than 15 mgs.
Low dose P is well tolerated and has very few side effects. Once the patient is in remission, we have found it relatively easy to taper the P and often are even able to discontinue it.
That isn't to say that patients shouldn't be counseled about P. We spend a great deal of time talking about the potential problems associated with this drug and monitor the patient carefully while they are on P.
Nonetheless, we have found the combination of low dose P along with methotrexate to be an effective one.