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One drug that is often used in the early treatment of rheumatoid arthritis is prednisone. Prednisone is a glucocorticoid. Glucocorticoids are drugs that have biologic activity similar to the hormones made in the adrenal glands.

These drugs are chemically synthesized and are used to treat a variety of inflammatory disorders.

Glucocorticoids, while very effective for treating inflammation, have many potential side effects including thinning of the skin, acne, weight gain, fluid retention, blood sugar elevation, cataracts, stomach ulcers, suppression of normal adrenal gland function, osteoporosis, psychosis, and avascular necrosis (bone death).

Most of these side effects occur when prednisone is given in high doses over an extended period of time. In rheumatoid arthritis, prednisone is used in low doses and gradually tapered depending on a patient's response to other medications such as disease modifying anti-rheumatic drugs (DMARDS) or biologics that are given concurrently with prednisone.

Unfortunately, though, the perception of prednisone, due to sensationalized media coverage is an undeservedly bad one.

A recent study of 440 Dutch patients with recent onset rheumatoid arthritis showed that in initial therapy, many would prefer not to have to take prednisone. (Goekoop-Ruiterman YPM, et al. Ann Rheum Dis 2007;66:1227-1232).

Lead author, Dr. Yvonne P. M. Goekoop-Ruiterman, stated "patients have a strong preference to receive treatment with the newest drug with promising results, and that dislike for prednisone seems to be strong and widespread."

Patients were randomized to take methotrexate alone, methotrexate in combination with another DMARD, methotrexate in combination with another DMARD plus a tapering dose of prednisone, or methotrexate plus a DMARD plus infliximab (Remicade), a tumor necrosis blocking biologic therapy.

Interestingly, half of the patients had no preference or aversion to a particular treatment group. One third wanted to be in the infliximab group, and about 38% had hoped not to start with prednisone.

Half of the patients in the prednisone group disliked taking the drug. By contrast, only 8% of the infliximab group disliked having to go to the hospital for intravenous therapy. (Infliximab is administered by vein).

The researchers stated, "The dislike of prednisone revolves around (mis)information about possible side effects, whereas for the newer TNF-blocking agents (such as infliximab), information appears to focus on the efficacy and less on possible (future) side effects. There is a need for better patient education about the efficacy and toxicity of both corticosteroids and TNF antagonists."

As a rheumatologist specializing in the treatment of rheumatoid arthritis, I feel that the judicious use of prednisone is extremely helpful in the management of clinically active disease, particularly early on. Also, it is often frustrating to have to deal with many of the misconceptions regarding the use of prednisone. Patient education and gaining the trust of the patient are key.