Rheumatoid arthritis

Glucocorticoids work for pain in rheumatoid arthritis but not for long

Systemic glucocorticoid treatment does reduce pain in people with active rheumatoid arthritis but the impact is time-limited, a large meta-analysis has concluded.

The review also showed some evidence of improvement in fatigue with glucocorticoid use in those with active disease, although the effect was small.

The results from an analysis of 33 studies found that pain improvement was most pronounced within three months of starting treatment and after six months may drop off substantially.

Writing in Rheumatology, the UK researchers said after six months fewer than half of participants on long-term glucocorticoid treatment have clinically meaningful benefit over placebo.

They also pointed out that there was no link between route of administration of treatment and analgesic affect.

An overall lack of dose response for pain for oral glucocorticoid, or between oral and parenteral treatment might suggest that maximum analgesic effect can be achieved with low doses of oral prednisolone – possibly 15mg daily or less, they concluded.

The meta analysis analysis quantified the effect on pain and found a mean difference in pain visual analogue scale of -12mm compared at less than three months, -8mm between three to six months and -6mm after six months. Similar findings were reported for spontaneous and evoked pain.

Effects on fatigue are an important outcome and are likely related to mechanisms within the central nervous system closely associated with central sensitisation and pain, the researchers said.

But the analgesic impact is more likely to be due to anti-inflammatory effects within joints rather than any effect on the CNS.

The researchers from Nottingham and Cambridge Universities noted that while systemic glucocorticoid are effective in reducing pain in active rheumatoid arthritis, the benefits may not outweigh the risk of long-term treatment.

And they concluded that current use of glucocorticoid appear to be largely guided by clinical experience rather than any robust evidence from randomised controlled trials.

“Many patients receive glucocorticosteroids often at high dose, when DMARDs have not controlled pain,” they said pointing to estimates in the US that up to a third of patients with rheumatoid arthritis might be using them regularly.

“Further research is needed to determine who could benefit most from systemic glucocorticosteroids to inform personalised treatment,” they said also calling for more research into other analgesic options.

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