In 1929, Dr. Philip Hench of the Mayo Clinic in Rochester, Minn., began noticing that patients with RA saw improvement in symptoms when their bodies were under other physiological stress – such as jaundice, pregnancy, surgery or infection.

Those observations led, nearly 20 years later, to the isolation and first use of what would be called cortisone.

Cortisone – the original corticosteroid – was considered a miracle drug at the time because of the dramatic and quick effect it had on rheumatoid arthritis. Newer treatments for the disease have come along, but corticosteroids – also commonly referred to as glucocorticoids – remain a powerful, if somewhat flawed, weapon in the anti-inflammatory arsenal, and there’s emerging evidence they do more than just provide symptomatic relief.

In fact, a recent study from the Netherlands, published in March 2012 in the Annals of Internal Medicine, found that adding the corticosteroid prednisone to a methotrexate regimen early in the disease process had numerous positive effects versus using methotrexate alone, including less joint damage, less physical disability and reduced disease activity. 

“The correct use of [corticosteroids] will help to protect the joints from future damage and will mean that some patients will not need to go on to other treatments, such as biological agents, which are more dangerous and much more expensive,” says John R. Kirwan, MD, of the University of Bristol Academic Rheumatology Unit, Bristol, United Kingdom.

Dr. Kirwan recently authored a commentary, also in the March 2012 Annals of Internal Medicine, suggesting that therapy with corticosteroids – specifically, prednisone – in conjunction with another disease-modifying antirheumatic drug, or DMARD, should be considered the “gold standard” for early treatment of RA. And yet, Dr. Kirwan admits some doctors avoid use of corticosteroids for RA, primarily because of concern about side effects.

The Ups and Downs of Corticosteroids

Without a doubt, prednisone and other drugs in the class do come with a substantial number of possible side effects – most of which are dose-related.

“Some of the side effects include weight gain, thinning of the skin, which can lead to increased bruising, says Stanley Cohen, MD, past president of the American College of Rheumatology ( ACR) and a practicing rheumatologist in Dallas. “There’s acceleration of bone loss with higher risk of fracture, increases in blood sugar and in every clinical trial, the group of patients on prednisone always had a greater risk of infection.”

To address bone loss, the ACR recommends base-line bone density measurements on patients using prednisone six months or longer, with additional monitoring and possible use of calcium and vitamin D supplements and/or prescription agents which help maintain bone density. 

Elena M. Massarotti, MD, a rheumatologist at the Brigham and Women’s Hospital, Boston, Mass., and an associate professor at Harvard University, calls the use of prednisone and other corticosteroids “the classic double-edged sword.”

“There’s some evidence prednisone in low doses may improve the radiographic features of rheumatoid arthritis,” Dr. Massarotti says. But, because of the high potential for side effects, as far as she’s concerned, the ideal duration of prednisone treatment would be “zero days.”