The Story Behind the Use of Glucocorticoids in the Treatment of Rheumatoid Arthritis.

Cortisone was introduced in the treatment of rheumatoid arthritis (RA) in 1948 by Hench and colleagues at the Mayo Clinic which resulted in dramatic improvement of inflammation, function and sense of well-being. It became obvious early on that side effects could develop depending on the dose and duration of use. When cortisone became available in 1950 the practicing physician developed practice patterns without guidance from government agencies, professional organizations or the pharmaceutic industry. The physician did not have guidance about what dose to use or the duration of use, as is available today. In the last 25 years, controlled studies have shown the benefits and safety of low dose prednisone in early RA. The diurnal effect of endogeneous glucocorticoids provides a clue to the timing of a glucocorticoid dose and the duration of the dose is established. The guidelines by the American College of Rheumatology (ACR) particularly but also the European League Against Rheumatism (EULAR) have emphasized side effects and stressed limited use of glucocorticoids in RA. Biologics have been developed and promoted that are used to replace and taper off low dose prednisone. Yet, glucocorticoids used appropriately can be the cornerstone of effective, safe, and inexpensive treatment of early active rheumatoid arthritis.