Short-term bridging therapy with low-dose prednisolone is achievable for most patients with newly diagnosed rheumatoid arthritis, a study has shown.
However, the Norwegian researchers have stressed the importance of implementing a structured tapering protocol and a close follow-up regimen for their trial results to be translatable to real-world practice.
Their study aimed to address the evidence gap on the discontinuation of glucocorticoids after initial bridging therapy for RA patients following a treat-to-target strategy, including the optimal dose and duration of bridging therapy.
International recommendations have been mixed, with the American College of Rheumatology advising against glucocorticoids altogether due to their toxicity and tapering challenges in its 2021 guideline. Whereas the European Alliance of Associations for Rheumatology (EULAR) suggests tapering within 3 months.
For two years the researchers followed 227 patients naïve to disease-modifying antirheumatic drugs (DMARDs) with recent-onset RA in the ARCTIC trial, who received prednisolone bridging therapy alongside methotrexate monotherapy.
Of the cohort, the mean age was 52, 62% were female, the mean disease activity score was 3.47 and 82% were anticitrullinated peptide antibody (ACPA) positive.
Prednisolone dose was reduced from 15 mg/d during week 1 to 0 over 7 weeks.
Findings showed high rates of successful prednisolone discontinuation, defined as sustained discontinuation for at least the following 4 months. At 2 months, 84% of patients had stopped prednisolone, at 3 months, 89%, and by two years, 95%.
Of all 227 patients, 11 (5%) continued using prednisolone at every follow-up visit.
This meant that nearly nine of 10 patients achieved discontinuation in line with the EULAR recommendation of within a 3-month period for low-dose glucocorticoids.
Among those who had stopped prednisolone after 7 weeks, 80% did not restart during follow-up.
The researchers observed that participants who continued prednisolone beyond the 7 weeks of bridging therapy required more DMARD adjustments, had higher biologic use, and achieved lower remission rates, indicating more severe disease.
“Although further research is necessary to determine predictors of unsuccessful tapering, short-term prednisolone bridging therapy appears effective for most patients with RA, with over 80% able to discontinue treatment after 7 weeks,” the researchers wrote in Annals of the Rheumatic Diseases [link here].
“However, translating this approach into routine care, where visits are less frequent, targets less clearly defined, and patients often have more comorbidities, requires adaptation. Implementing standardised tapering protocols, proactive DMARD escalation, patient education, and systematic monitoring could help replicate trial success and minimise long-term harm.”
The researchers said the 7-week prednisolone bridging therapy had been included in the national guidelines for RA management in Norway.
Currently the Australian Living Guidelines recommend consideration of a short course of glucocorticoids in people with active RA who are initiating, switching or adding DMARD therapy, using the lowest effective dose until DMARDs take effect.
The guidelines, co-produced by the ARA and ANZMUSC, state that a shared plan for dose reduction and discontinuation of bridging glucocorticoids should be developed at the start of the treatment course and regularly reviewed.