Progression of radiographic joint erosion during low dose corticosteroid treatment of rheumatoid arthritis

Objective, The reported prevention of joint damage during treatment with prednisolone 7.5 mg daily in patients with early rheumatoid arthritis (RA)(3) may have important implications for management of RA. We evaluated this observation in another patient population. Methods. Radiographic progression rates in paired hand radiographs were analyzed in 824 patients with RA who participated in a 3 year prospective, randomized clinical trial comparing the nonsteroidal antiinflammatory drugs (NSAID) etodolac (150 or 500 mg bid) and ibuprofen (600 mg qid). Disease modifying antirheumatic drugs (DMARD) were not permitted. Prednisone less than or equal to 5 mg daily was continued by 197 patients (mean dose 4.37 mg daily) who had started prednisone therapy at least 6 mo before study entry, but new prednisone starts were not allowed. Standardized hand/wrist radiographs were done yearly and at dropout; joint erosion and narrowing scores of 3 readers were averaged and progression rates were compared. Results. Mean duration of RA was 3.6 years (range 1-7); patients' ages were 21-78 years; 71% were women. Among the 824 patients, those taking prednisone were more likely to have had previous DMARD, and at study entry had higher radiographic scores for joint erosion and joint space narrowing and slightly higher swollen joint counts, C-reactive protein values, and rheumatoid factor titers than those not taking prednisone. However, for the subgroup of 252 patients with RA duration of 12-24 months, prestudy radiographic scores were not different in those taking or not taking prednisone. The mean (+/- SD) monthly rate of increase in erosion scores was 0.228 +/- 0.37 for the prednisone patients and 0.206 +/- 0.35 for patients not taking prednisone (p = 0.994 by ANCOVA), The subgroup with 12 to 24 months' disease duration at. entry also showed no significant effect of prednisone treatment on erosion progression. Conclusion. Clinically indicated low dose prednisone did not prevent progressive radiographic damage in 197 NSAID treated patients whose physicians had initiated 7.5 mg daily before study entry. The risk/benefit ratio of chronic low dose prednisone in early RA remains uncertain.