Steroids for Rheumatoid Arthritis: Misconceptions & the reality


More bad than good comes to one’s mind when steroids are mentioned, isn’t it? Steroids (Glucocorticoids) have been equated with all that allopathy has to offer for its arthritis patients. It is thought that each & every patient consulting a Rheumatologist would be on long-term steroids irrespective of his diagnosis & would invariably end up with side effects.

Glucocorticoids (popularly known as steroids) were discovered by Scientist Hench. It was a path-breaking discovery & Hench was awarded the Nobel Prize for this in 1950.
Steroids when introduced were used for Rheumatoid Arthritis (RA). As expected they had miraculous results. It was thought that a cure for Rheumatoid Arthritis was in the making. Variable doses were given for variable duration as everyone was on a learning curve. Soon, the side effects were realised. Search began for better medications. This resulted in the development of DMARDs & later biologics that have revolutionized the treatment & outcome of Rheumatoid Arthritis. Not just new drugs, but treatment strategies such as ‘treat to target’ were developed to ensure remission in RA.

So then, if not for steroids, how is RA treated now?
RA is now treated with a target of remission (absolute control of arthritis) right from day 1. Patients are started on DMARDs; generally a combination with Methotrexate as the anchor drug. The DMARD doses are stepped up with the aim of achieving remission asap. If the patient fails to show a good response by six months, biologics come into the picture.
What about steroids in that case? What is its role? Steroids are given to begin with as a bridge till the time DMARDs have their effect. This would mean a small dose of steroid for 4-6 weeks.

However, there a few situations in which steroids have to be given in the long run. These include
1) Rheumatoid Arthritis related Interstitial Lung Disease
2) Rheumatoid vasculitis – this can present as vasculitic ulcers
3) Rheumatoid Arthritis related mononeuritis multiplex (damage to multiple peripheral nerves)
4) Rheumatoid Arthritis related scleromalacia (an eye complication)
5) An occasional patient who has persistent active arthritis despite DMARDs & cannot afford biologics.
All in all, steroids have a well-defined role & use as far as Rheumatoid Arthritis is concerned & one does not have to be on long-term steroids unless for some specific indications.

RAers, keep an emergency plan handy!

I’m sure all of you know that Rheumatoid arthritis (RA) is characterized by remissions & exacerbations. The aim of treatment is to keep your RA in remission & avoid flares as much as possible.

What is a RA flare?
RA flare describes an exacerbation of RA activity. It is the period when joints start hurting & are swollen.

What brings on a RA flare?
1. Change of weather. Sudden rain/ winter generally is responsible.
2. Physical exertion
3. Mental stress
4. Dietary changes. Sour food items tend to bring a flare in many RAers.
5. Stopping of medications.

How does a flare affect you?
1. The pain & suffering due to the joint inflammation.
2. If the flare gets prolonged, the dose of other DMARDs would eventually go up.

The best way to take care of a flare is to detect it early & treat is asap. You may contact your Rheumatologist & consult him immediately. However this may not always be feasible. The waiting list at your Rheumie’s clinic may not always allow you an immediate consultation.

Hence, speak to your Rheumie when you visit him the next time & get an emergency plan ready.

The emergency plan
1. An analgesic (NSAID) that you can immediately take when you sense a flare. Ask you rheumy about the number of tablets that you can take in a day, the interval you need to keep between 2 tablets. NSAIDs are never taken on empty stomach. Always eat something before taking a NSAID to avoid gastritis (acidity).
2. Ask your Rheumie if you can take a small short course of a steroid in case of a severe flare. You need to understand that steroids are not to be continued in the long run & you can start it & see your Rhumie asap. Speak to him regarding the dose & duration.
3. Once you sense a flare, put the plan in action immediately. The best way to take care of a flare is to treat it immediately.
4. Always take adequate rest during a flare.