A spirited debate was published in the Rheumatologist,
a magazine I get. The topic was the use of prednisone in rheumatoid arthritis. Recent
guidelines produced by the American College of Rheumatology regarding treatment of rheumatoid
arthritis omitted the use of prednisone. Dr. John Kirwan, a professor at the University
of Bristol, who wrote several papers showing that prednisone had disease-modifying effects
and held back the destructive processes of rheumatoid arthritis (RA) made his pitch.
He advocated the use of prednisone in combination therapy for this condition.
Dr. Theodore Pincus, a professor at NYU, advocated the use of low dose prednisone (less than
or equal to 5 mgs a day). He provided evidence that it was safe and effective at that dose.
Dr. Anthony S. Russell, a professor at the University of Alberta issued the counterpoint.
He provided historical data showing that prednisone had long term toxicity without significant
benefit (in his opinion.) With all due respect to Dr. Russell, much
of the data he cited was old data when higher doses of prednisone were used. He also contended
that primary care doctors would be tempted to use prednisone if they saw rheumatologists
using it. My opinion is this. I use low dose prednisone
a lot in my practice. By low dose, I mean 5 mgs or less. I think it is effective as
an add- on therapy. It is also a great “bridge” if the patient is transitioning therapies.
I have seen very little long term toxicity associated with this low dose approach. And
I think the benefits derived from improved activities of daily living far outweigh the
negatives. I do think that doses higher than 5 mgs should be avoided if possible. I also
don’t think the primary care issue is that big a deal although I admit… I have seen
some indiscriminate use in my community.