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Current Rheumatology Reviews

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ISSN (Print): 1573-3971
ISSN (Online): 1875-6360

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Research Article

Diagnostic Value of Short Course Low-dose Prednisolone in Patients with Clinically Suspected Seronegative Inflammatory Arthritis - A Retrospective Study

Author(s): Sam Shan* and Mueed Mian

Volume 20, Issue 3, 2024

Published on: 01 January, 2024

Page: [296 - 303] Pages: 8

DOI: 10.2174/0115733971273652231213092458

Price: $65

Abstract

Objective: We aim to establish the utility of a trial of low-dose systemic glucocorticoid therapy in the assessment of new clinically suspected inflammatory arthritis patients.

Methods: We retrospectively identified patients from a private rheumatology practice in Melbourne, Australia between January 1st, 2019, and December 31st, 2021, who presented with clinically suspected inflammatory arthritis and subsequently underwent a trial of low-dose prednisolone (15 mg daily weaned over three weeks in 5 mg increments). We excluded patients with known autoimmune/ inflammatory disorders or concurrent immunosuppression at presentation. We collected basic participant demographic details and clinical details of their presentation, glucocorticoid response, investigations, and treatment.

Results: We recruited 177 participants with a median age of 52, and 69.5% were female gender. The median symptom time to presentation was 12 months. Hands were the most affected joint in 63.3% and 85% had bilateral disease. Among the participants, 29.4% had synovitis on clinical review and 75.7% had imaging performed as part of the initial assessment. At presentation, the median CRP was 11 and the median ESR was 16. 79.7% of the cohort experienced significant improvement in their arthritis symptoms from low-dose glucocorticoids and 83.6% of the cohort required long-term immunosuppression for an underlying inflammatory condition. Of those who responded to glucocorticoids, 92.1% were diagnosed with an inflammatory condition. Rheumatoid arthritis was the most common overall diagnosis in 28%.

Conclusion: An initial trial of low-dose glucocorticoids in undifferentiated arthritis patients is useful in predicting the diagnosis of inflammatory arthritis. It is also a predictor of further long-term steroid-sparing therapy.

Keywords: Glucocorticoid therapy, low-dose prednisolone, inflammatory disorders, immunosuppression, rheumatoid arthritis, long-term steroid-sparing therapy.

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[1]
Kobelt G, Woronoff AS, Richard B, Peeters P, Sany J. Disease status, costs and quality of life of patients with rheumatoid arthritis in France: The ECO-PR Study. Joint Bone Spine 2008; 75(4): 408-15.
[http://dx.doi.org/10.1016/j.jbspin.2007.07.015] [PMID: 18455949]
[2]
Coffey CM, Crowson CS, Myasoedova E, Matteson EL, Davis JM III. Evidence of diagnostic and treatment delay in seronegative rheumatoid arthritis: Missing the window of opportunity. Mayo Clin Proc 2019; 94(11): 2241-8.
[http://dx.doi.org/10.1016/j.mayocp.2019.05.023] [PMID: 31619364]
[3]
Wendling D, Claudepierre P, Prati C. Early diagnosis and management are crucial in spondyloarthritis. Joint Bone Spine 2013; 80(6): 582-5.
[http://dx.doi.org/10.1016/j.jbspin.2013.03.003] [PMID: 23578940]
[4]
Burke CJ, Alizai H, Beltran LS, Regatte RR. MRI of synovitis and joint fluid. J Magn Reson Imaging 2019; 49(6): 1512-27.
[http://dx.doi.org/10.1002/jmri.26618] [PMID: 30618151]
[5]
van Nies JAB, Krabben A, Schoones JW, Huizinga TWJ, Kloppenburg M, van der Helm-van Mil AHM. What is the evidence for the presence of a therapeutic window of opportunity in rheumatoid arthritis? A systematic literature review. Ann Rheum Dis 2014; 73(5): 861-70.
[http://dx.doi.org/10.1136/annrheumdis-2012-203130] [PMID: 23572339]
[6]
van der Linden MPM, le Cessie S, Raza K, et al. Long-term impact of delay in assessment of patients with early arthritis. Arthritis Rheum 2010; 62(12): 3537-46.
[http://dx.doi.org/10.1002/art.27692] [PMID: 20722031]
[7]
Lukas C, Combe B, Ravaud P, Sibilia J, Landew R, van der Heijde D. Favorable effect of very early disease-modifying antirheumatic drug treatment on radiographic progression in early inflammatory arthritis: Data from the Étude et Suivi des Polyarthrites IndifféRenciées récentes (Study and Followup of Early Undifferentiate. Arthritis Rheum 2011; 63(7): 1804-11.
[http://dx.doi.org/10.1002/art.30371] [PMID: 21452295]
[8]
Holroyd CR, Seth R, Bukhari M, et al. The British Society for Rheumatology biologic DMARD safety guidelines in inflammatory arthritis—Executive summary. Rheumatology 2019; 58(2): 220-6.
[http://dx.doi.org/10.1093/rheumatology/key207] [PMID: 30137623]
[9]
Aletaha D, Kapral T, Smolen JS. Toxicity profiles of traditional disease modifying antirheumatic drugs for rheumatoid arthritis. Ann Rheum Dis 2003; 62(5): 482-6.
[http://dx.doi.org/10.1136/ard.62.5.482] [PMID: 12695166]
[10]
Grierson DJ. Hydroxychloroquine and visual screening in a rheumatology outpatient clinic. Ann Rheum Dis 1997; 56(3): 188-90.
[http://dx.doi.org/10.1136/ard.56.3.188] [PMID: 9135223]
[11]
Fries JF, Williams CA, Ramey D, Bloch DA. The relative toxicity of disease-modifying antirheumatic drugs. Arthritis Rheum 1993; 36(3): 297-306.
[http://dx.doi.org/10.1002/art.1780360303] [PMID: 8452574]
[12]
Krause ML, Amin S, Makol A. Use of DMARDs and biologics during pregnancy and lactation in rheumatoid arthritis: What the rheumatologist needs to know. Ther Adv Musculoskelet Dis 2014; 6(5): 169-84.
[http://dx.doi.org/10.1177/1759720X14551568] [PMID: 25342996]
[13]
van der Heijde DMFM. Joint erosions and patients with early rheumatoid arthritis. Rheumatology 1995; XXXIV (Suppl. 2): 74-8.
[http://dx.doi.org/10.1093/rheumatology/XXXIV.suppl_2.74] [PMID: 8535653]
[14]
Krabben A, Stomp W, van Nies JAB, et al. MRI-detected subclinical joint inflammation is associated with radiographic progression. Ann Rheum Dis 2014; 73(11): 2034-7.
[http://dx.doi.org/10.1136/annrheumdis-2014-205208] [PMID: 25074691]
[15]
van Steenbergen HW, van Nies JAB, Huizinga TWJ, Bloem JL, Reijnierse M, van der Helm-van Mil AHM. Characterising arthralgia in the preclinical phase of rheumatoid arthritis using MRI. Ann Rheum Dis 2015; 74(6): 1225-32.
[http://dx.doi.org/10.1136/annrheumdis-2014-205522] [PMID: 24718962]
[16]
Narváez JA, Narváez J, De Lama E, De Albert M. MR imaging of early rheumatoid arthritis. Radiographics 2010; 30(1): 143-63.
[http://dx.doi.org/10.1148/rg.301095089] [PMID: 20083591]
[17]
Paalanen K, Puolakka K, Nikiphorou E, Hannonen P, Sokka T. Is seronegative rheumatoid arthritis true rheumatoid arthritis? A nationwide cohort study. Rheumatology 2021; 60(5): 2391-5.
[http://dx.doi.org/10.1093/rheumatology/keaa623] [PMID: 33175968]
[18]
Paalanen K, Rannio K, Rannio T, Asikainen J, Hannonen P, Sokka T. Does early seronegative arthritis develop into rheumatoid arthritis? A 10-year observational study. Clin Exp Rheumatol 2019; 37(1): 37-43.
[PMID: 29998832]
[19]
Palmowski Y, Buttgereit T, Dejaco C, et al. “Official View” on glucocorticoids in rheumatoid arthritis: A systematic review of international guidelines and consensus statements. Arthritis Care Res 2017; 69(8): 1134-41.
[http://dx.doi.org/10.1002/acr.23185] [PMID: 28029750]
[20]
Smolen JS, Landewé R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis 2017; 76(6): 960-77.
[http://dx.doi.org/10.1136/annrheumdis-2016-210715] [PMID: 28264816]
[21]
Singh JA, Saag KG, Bridges SL Jr, et al. 2015 american college of rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol 2016; 68(1): 1-26.
[http://dx.doi.org/10.1002/art.39480] [PMID: 26545940]
[22]
Stacy JM, Greenmyer JR, Beal JR, Sahmoun AE, Diri E. The efficacy of low dose short-term prednisone therapy for remission induction in newly diagnosed rheumatoid arthritis patients. Adv Rheumatol 2021; 61(1): 50.
[http://dx.doi.org/10.1186/s42358-021-00205-4] [PMID: 34372936]
[23]
Bandinelli F, Scazzariello F, Pimenta da Fonseca E, et al. Low- dose modified-release prednisone in axial spondyloarthritis: 3- month efficacy and tolerability. Drug Des Devel Ther 2016; 10: 3717-24.
[http://dx.doi.org/10.2147/DDDT.S115099] [PMID: 27881910]
[24]
Buttgereit F, Saag KG, Cutolo M, da Silva JAP, Bijlsma JWJ. The molecular basis for the effectiveness, toxicity, and resistance to glucocorticoids: Focus on the treatment of rheumatoid arthritis. Scand J Rheumatol 2005; 34(1): 14-21.
[http://dx.doi.org/10.1080/03009740510017706] [PMID: 15903020]
[25]
Lenti MV, Rossi CM, Melazzini F, et al. Seronegative autoimmune diseases: A challenging diagnosis. Autoimmun Rev 2022; 21(9): 103143.
[http://dx.doi.org/10.1016/j.autrev.2022.103143] [PMID: 35840037]
[26]
Shan S, Foote A, Mian M. 2023 Australian rheumatology association (ARA) 63rd annual scientific meeting, 6-9 May 2023, Hobart, Tasmania. Intern Med J 2023; 53 (Suppl. 1): 5-57.
[PMID: 37095745]
[27]
Schäcke H, Schottelius A, Döcke WD, et al. Dissociation of transactivation from transrepression by a selective glucocorticoid receptor agonist leads to separation of therapeutic effects from side effects. Proc Natl Acad Sci USA 2004; 101(1): 227-32.
[http://dx.doi.org/10.1073/pnas.0300372101] [PMID: 14694204]
[28]
Coutinho AE, Chapman KE. The anti-inflammatory and immunosuppressive effects of glucocorticoids, recent developments and mechanistic insights. Mol Cell Endocrinol 2011; 335(1): 2-13.
[http://dx.doi.org/10.1016/j.mce.2010.04.005] [PMID: 20398732]
[29]
Magyari L, Varszegi D, Kovesdi E, et al. Interleukins and interleukin receptors in rheumatoid arthritis: Research, diagnostics and clinical implications. World J Orthop 2014; 5(4): 516-36.
[http://dx.doi.org/10.5312/wjo.v5.i4.516] [PMID: 25232528]
[30]
Da Silva JAP, Jacobs JW, Kirwan JR, et al. Safety of low dose glucocorticoid treatment in rheumatoid arthritis: Published evidence and prospective trial data. Ann Rheum Dis 2006; 65(3): 285-93.
[http://dx.doi.org/10.1136/ard.2005.038638] [PMID: 16107513]
[31]
Saag KG, Koehnke R, Caldwell JR, et al. Low dose long-term corticosteroid therapy in rheumatoid arthritis: An analysis of serious adverse events. Am J Med 1994; 96(2): 115-23.
[http://dx.doi.org/10.1016/0002-9343(94)90131-7] [PMID: 8109596]
[32]
Noetzlin S, Breville G, Seebach JD, Gastaldi G. Short-term glucocorticoid-related side effects and adverse reactions: A narrative review and practical approach. Swiss Med Wkly 2022; 152(102): w30088.
[http://dx.doi.org/10.4414/SMW.2022.w30088] [PMID: 35019245]
[33]
Huscher D, Thiele K, Gromnica-Ihle E, et al. Dose-related patterns of glucocorticoid-induced side effects. Ann Rheum Dis 2009; 68(7): 1119-24.
[http://dx.doi.org/10.1136/ard.2008.092163] [PMID: 18684744]
[34]
Boers M, Hartman L, Opris-Belinski D, et al. Low dose, add-on prednisolone in patients with rheumatoid arthritis aged 65+: the pragmatic randomised, double-blind placebo-controlled GLORIA trial. Ann Rheum Dis 2022; 81(7): 925-36.
[http://dx.doi.org/10.1136/annrheumdis-2021-221957] [PMID: 35641125]
[35]
van der Goes MC, Jacobs JWG, Boers M, et al. Monitoring adverse events of low-dose glucocorticoid therapy: EULAR recommendations for clinical trials and daily practice. Ann Rheum Dis 2010; 69(11): 1913-9.
[http://dx.doi.org/10.1136/ard.2009.124958] [PMID: 20693273]
[36]
Montecucco C, Todoerti M, Sakellariou G, Scirè CA, Caporali R. Low-dose oral prednisone improves clinical and ultrasonographic remission rates in early rheumatoid arthritis. Results of a 12 month open-label randomized study. Arthritis Res Ther 2012; 14(3): R112.
[http://dx.doi.org/10.1186/ar3838] [PMID: 22584017]
[37]
Buttgereit F, da Silva JA, Boers M, et al. Standardised nomenclature for glucocorticoid dosages and glucocorticoid treatment regimens: Current questions and tentative answers in rheumatology. Ann Rheum Dis 2002; 61(8): 718-22.
[http://dx.doi.org/10.1136/ard.61.8.718] [PMID: 12117678]
[38]
Stahn C, Buttgereit F. Genomic and nongenomic effects of glucocorticoids. Nat Clin Pract Rheumatol 2008; 4(10): 525-33.
[http://dx.doi.org/10.1038/ncprheum0898] [PMID: 18762788]
[39]
C Strehl CMS. F Buttgereit. Pharmacodynamics of glucocorticoids. Clin Exp Rheumatol 2011; 29(5) (Suppl. 68): S13-8.
[40]
McWilliams DF, Thankaraj D, Jones-Diette J, et al. The efficacy of systemic glucocorticosteroids for pain in rheumatoid arthritis: a systematic literature review and meta-analysis. Rheumatology 2021; 61(1): 76-89.
[http://dx.doi.org/10.1093/rheumatology/keab503] [PMID: 34213524]
[41]
Vincken NLA, Balak DMW, Knulst AC, Welsing PMJ, van Laar JM. Systemic glucocorticoid use and the occurrence of flares in psoriatic arthritis and psoriasis: A systematic review. Rheumatology 2022; 61(11): 4232-44.
[http://dx.doi.org/10.1093/rheumatology/keac129] [PMID: 35285486]
[42]
Dhir V, Mishra D, Samanta J. Glucocorticoids in spondyloarthritis—systematic review and real-world analysis. Rheumatology 2021; 60(10): 4463-75.
[http://dx.doi.org/10.1093/rheumatology/keab275] [PMID: 33748829]
[43]
Kennedy-Martin T, Curtis S, Faries D, Robinson S, Johnston J. A literature review on the representativeness of randomized controlled trial samples and implications for the external validity of trial results. Trials 2015; 16(1): 495.
[http://dx.doi.org/10.1186/s13063-015-1023-4] [PMID: 26530985]
[44]
Rothwell PM. External validity of randomised controlled trials: “To whom do the results of this trial apply?”. Lancet 2005; 365(9453): 82-93.
[http://dx.doi.org/10.1016/S0140-6736(04)17670-8] [PMID: 15639683]
[45]
Sniderman AD, LaChapelle KJ, Rachon NA, Furberg CD. The necessity for clinical reasoning in the era of evidence-based medicine. Mayo Clin Proc 2013; 88(10): 1108-14.
[http://dx.doi.org/10.1016/j.mayocp.2013.07.012] [PMID: 24079680]
[46]
Dorleijn DMJ, Luijsterburg PAJ, Reijman M, et al. Intramuscular glucocorticoid injection versus placebo injection in hip osteoarthritis: A 12-week blinded randomised controlled trial. Ann Rheum Dis 2018; 77(6): annrheumdis-2017-212628.
[http://dx.doi.org/10.1136/annrheumdis-2017-212628] [PMID: 29514801]
[47]
Wenham CYJ, Hensor EMA, Grainger AJ, et al. A randomized, double-blind, placebo-controlled trial of low-dose oral prednisolone for treating painful hand osteoarthritis. Rheumatology (Oxford) 2012; 51(12): 2286-94.
[http://dx.doi.org/10.1093/rheumatology/kes219] [PMID: 22956551]
[48]
Kroon FPB, Kortekaas MC, Boonen A, et al. Results of a 6-week treatment with 10 mg prednisolone in patients with hand osteoarthritis (HOPE): A double-blind, randomised, placebo-controlled trial. Lancet 2019; 394(10213): 1993-2001.
[http://dx.doi.org/10.1016/S0140-6736(19)32489-4] [PMID: 31727410]
[49]
Janssens HJEM, Janssen M, van de Lisdonk EH, van Riel PLCM, van Weel C. Use of oral prednisolone or naproxen for the treatment of gout arthritis: A double-blind, randomised equivalence trial. Lancet 2008; 371(9627): 1854-60.
[http://dx.doi.org/10.1016/S0140-6736(08)60799-0] [PMID: 18514729]
[50]
Kyle V, Hazleman BL. Treatment of polymyalgia rheumatica and giant cell arteritis. I. Steroid regimens in the first two months. Ann Rheum Dis 1989; 48(8): 658-61.
[http://dx.doi.org/10.1136/ard.48.8.658] [PMID: 2782975]
[51]
Mathiessen A, Conaghan PG. Synovitis in osteoarthritis: Current understanding with therapeutic implications. Arthritis Res Ther 2017; 19(1): 18.
[http://dx.doi.org/10.1186/s13075-017-1229-9] [PMID: 28148295]

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