Moderate-term, low-dose corticosteroids for rheumatoid arthritis

  • Review
  • Intervention

Authors


Abstract

Background

Low dose corticosteroid use in RA is currently widespread with up to 80% of patients using prednisone or similar corticosteroid preparations in many arthritis practices, but the value of corticosteroids for the treatment of RA has been debated by several authors.

Objectives

To perform a systematic review of low-dose corticosteroid efficacy in the moderate term for the treatment of rheumatoid arthritis (RA).

Search methods

We searched MEDLINE from 1966 to 1998, using the keywords "corticosteroids" and "rheumatoid arthritis". We also handsearched all issues of Arthritis and Rheumatism and the Scandinavian Journal of Rheumatology from their dates of first publication to 1994 and examined all Arthritis and Rheumatism abstracts over the 15 year period preceding 1994. References of all identified studies were searched for relevant trials. Authors of unpublished manuscripts were contacted.

Selection criteria

We required that trials be randomized or cross-over and report at least one of the outcome measures of interest. We also required that trials be of at least three months duration and use prednisone (or a comparable corticosteroid preparation) at a mean dosage of less than or equal to 15 mg/day, compared to placebo or active drug controls.

Data collection and analysis

Data was abstracted by two independent reviewers (LC, KS) using a standard form. We reported results for all available outcomes recommended by the Outcome Measures for Rheumatology Trials (OMERACT) group.

Main results

Very few studies directly assessed the effectiveness of corticosteroids for RA treatment and many were of poor methodologic quality. Only seven of 34 studies identified by our search met criteria for inclusion. Our results indicated that corticosteroids were significantly more effective than placebo controls for four of six outcomes assessed [standardized mean difference for tender joints = -0.37 (95%CI: -0.59, -0.14), swollen joints = -0.41 (-0.67, -0.16), pain = -0.43 (-0.74, -0.12), and functional status = -0.57 (-0.92, -0.22)]. The results for grip strength and ESR were not significant [GS = +0.30 (-0.19, +0.80), weighted mean difference (WMD) for ESR = -7.03 (-18.06, +4.01)]. The single trial that compared prednisone to aspirin indicated no statistically significant difference between these groups for joint tenderness (0.10 (-0.35, +0.55) and for ESR [0.00 (-11.09, +11.09]. Overall, the four outcomes assessed in the single trial that compared prednisone to chloroquine suggested that there was no statistically significant differenece in the effectiveness of these two agents [SMD for joint tenderness = +0.23 (-0.30, +0.75), swollen joints = +0.43 (-0.11, +0.96), functional status = -0.27 (-0.80, +0.26), and WMD for ESR = -16.00 (-30.58, -1.42)].

Authors' conclusions

Based on the limited data available, moderate-term prednisone treatment of RA appears to be superior to placebo and comparable to treatment with aspirin or chloroquine in improving several common rheumatoid arthritis disease activity measures.

摘要

背景

中期低劑量類固醇用於治療類風濕性關節炎

低劑量類固醇用於治療類風濕性關節炎是常見處置,約80% 以上使用,但其價值仍有爭議。

目標

系統回顧低劑量類固醇用於治療類風濕性關節炎之中期效用

搜尋策略

搜尋包括用corticosteroids and rheumatoid arthritis 當關鍵字,MEDLINE搜尋1966到1998,同時手動搜尋Arthritis and Rheumatism and the Scandinavian Journal of Rheumatology. 及搜尋回顧文章之參考文獻及詢問專家。

選擇標準

選入隨機對照試驗或交叉試驗研究,並且報告至少一個結果,並且要求使用類固醇每日小於等於15毫克,至少3個月以上,比上安慰劑或其它藥物。

資料收集與分析

兩位作者進行資料摘錄於標準格式及進行品質評估。結果為Outcome Measures for Rheumatology Trials (OMERACT)建議。

主要結論

少有低劑量類固醇用於治療類風濕性關節炎之直接研究,但品質及報告數據不一。本文34篇中7篇符合選入條件。根據資料,低劑量類固醇用於治療類風濕性關節炎對改善關節炎活性比安慰劑好,在6項結果評估中4項有顯著差異。[standardized mean difference 疼痛關節 0.37 (95% CI: −0.59, −0.14), 腫脹關節 −0.4 −0.67, −0.16), 疼痛 −0.43 (−0.74, −0.12), 功能狀態 −0.57 (−0.92, −0.22)]。對握力及ESR未有顯著差異 握力 +0.30 (−0.19, +0.80), ESR加權平均差異 7.03 (−18.06, +4.01)]。 單篇研究比較類固醇與阿斯匹靈顯示在關節疼痛 0.10 (−0.35, +0.55)及ESR 0.00 (−11.09, +11.09) 無顯著差異。整體而言,比較類固醇與氯奎寧之單篇研究顯示在關節疼痛標準平均差異 +0.2 −0.30, +0.75)、關節腫痛 +0.43 (−0.11, +0.96)、功能狀態 0.27 (−0.80, +0.26) 及加權平均差異ESR16.00 (−30.58, −1.42) 無顯著差異。

作者結論

根據有限資料,中期低劑量類固醇用於治療類風濕性關節炎對改善關節炎多項疾病活性指標比安慰劑組好,而與阿斯匹靈或氯奎寧相當。

翻譯人

本摘要由林口長庚醫院余光輝翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

無總結

Plain language summary

The effectiveness of low-dose corticosteroids in the treatment of rheumatoid arthritis disease activity over the moderate term

Low dose corticosteroid use in RA is currently widespread with up to 80% of patients using prednisone or similar corticosteroid preparations in many arthritis practices, but the value of corticosteroids for the treatment of RA has been debated by several authors.

We included studies that used prednisone (or a comparable corticosteroid preparation) at a mean dose of less than or equal to 15 mg per day. We included studies that utilized either placebo controls or active controls (i.e. comparative studies).

Very few studies directly assessed the effectiveness of corticosteroids for RA treatment and many were of poor methodologic quality. Only seven of 34 studies identified by our search met criteria for inclusion. Our results indicated that corticosteroids were significantly more effective than placebo controls for four of six outcomes assessed [standardized mean difference for tender joints = -0.37 (95%CI: -0.59, -0.14), swollen joints = -0.41 (-0.67, -0.16), pain = -0.43 (-0.74, -0.12), and functional status = -0.57 (-0.92, -0.22)]. The results for grip strength and ESR were not significant [GS = +0.30 (-0.19, +0.80), weighted mean difference (WMD) for ESR = -7.03 (-18.06, +4.01)]. The single trial that compared prednisone to aspirin indicated no statistically significant difference between these groups for joint tenderness (0.10 (-0.35, +0.55) and for ESR [0.00 (-11.09, +11.09]. Overall, the four outcomes assessed in the single trial that compared prednisone to chloroquine suggested that there was no statistically significant differenece in the effectiveness of these two agents [SMD for joint tenderness = +0.23 (-0.30, +0.75), swollen joints = +0.43 (-0.11, +0.96), functional status = -0.27 (-0.80, +0.26), and WMD for ESR = -16.00 (-30.58, -1.42)].

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