[Glucocorticoid-free and low-dose glucocorticoid treatment of rheumatoid arthritis]

Systemic glucocorticoids (GC) are a commonly used component in the treatment of rheumatoid arthritis. The aim of this article is to show the evidence for low-dose GC or GC-free RA treatment regimens. Furthermore, concepts for the de-escalation of GC treatment for RA are presented. There is sufficient evidence in the initial phase that GC treatment in addition to methotrexate (MTX) improves the patient's response to the disease activity as well as the subjective perception of impairments. The dosage of GC, however, needs to be weighed critically and the guideline-based gradual reduction leading eventually to discontinuation must consistently be pursued. In the later phases of the treatment algorithm the risks of GC administration outweigh the benefits and long-term GC treatment should therefore be reserved for exceptional cases. The lowest possible dosage always needs to be determined individually. This can be achieved by using a clinically tested scheme of reducing the prednisolone intake by 1 mg every 4 weeks. The scheme should be considered for patients with a low disease activity or remission due to disease-modifying antirheumatic drug (DMARD) treatment, if they receive 5 mg of prednisolone as long-term treatment. On the whole the positive subjective effects of GC treatment must always be weighed up against the risks of such treatment for RA patients. An ongoing process of readjusting treatment following shared-decision rules must both consistently adapt GC doses and constantly check the indications. Even if a GC-free treatment does not seem realistic, a low-dose GC treatment of RA still is and should be pursued to reduce the risks associated with the treatment.