Although symptom relief is dramatic, there is a reluctance to use systemic corticosteroid for rheumatoid disease because of its adverse effects but this course is justified in some circumstances.
• To provide interim relief of inflammatory symptoms during the weeks that it takes DMARDs to act.
• Spaced single enormous doses (pulse treatment), e.g. methylprednisolone (as sodium succinate) up to 1 g i.v. on 3 consecutive days, are sometimes used to suppress highly active inflammatory disease and buy time to change the DMARD or dose.
• In extreme severity, high-dose prednisolone (20-40 mg/ d) will very effectively suppress inflammation, e.g. with vasculitis or rheumatoid lung.
• Where DMARDs have failed or have produced intolerable adverse effects. The object is to control inflammation in affected joints whilst minimising adverse effects, e.g. prednisolone 7.5 mg or its equivalent of other steroid given once daily (at 08:00 h to reduce adrenal-pituitary suppression).
• There is evidence that prednisolone 7.5 mg/day added to standard treatment may reduce the rate of joint destruction in moderate or severe disease of less than 2 years duration.10
Intra-articular injection of corticosteroid (triamcinolone, hydrocortisone, prednisolone or dex-amethasone) is very effective when one joint is more affected than others. Benefit from one injection may last many weeks. Aseptic precautions must be extreme, for any introduced infection may spread dramatically. Too frequent resort to corticosteroid injection may actually promote joint damage by removing the protective limitation conferred by pain; such injections in a single joint would not normally exceed three per year. Other aspects of the treatment of inflammatory arthritis are important but are outside the scope of this book.
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