The usual dosage is 3 g/day for sulfasalazine [58] and [59] and 20 mg/day for leflunomide. The absence of contraindications and good tolerance of these treatments should be checked. Hydroxychloroquine can be useful in combination with other synthetic DMARDs or with biologics but is not recommended alone in RA due to its weak and delayed clinical efficacy and absence of proven structural effects [57]. Nearly one of every three patients with RA receives long-term glucocorticoid therapy [60]. However, the risk/benefit ratio of glucocorticoid therapy remains controversial. In addition to symptomatic effects, structural effects of glucocorticoids were documented in several studies [61], [62], [63],

[64] and [65]. The structural efficacy of glucocorticoid therapy has been proven only in recent-onset RA and over a treatment duration of 1–2 years [65]. A recently reported 2-year BMS-754807 cell line randomized controlled trial (CAMERA II) compared methotrexate alone to methotrexate plus prednisone 10 mg/day [66].

After 2 years, the modified Sharp erosion score (primary outcome measure) was significantly lower in selleck chemicals llc the glucocorticoid group, which also had significantly fewer patients free of radiographic disease progression (78% versus 67% with the placebo) [66]. However, the use of a 10-mg prednisone dose for 2 years raises concerns, particularly regarding safety. In a meta-analysis, the rate of adverse events in RA patients receiving glucocorticoid therapy was 43/100 patient-years (95% confidence interval, 30–55) [67]. A case-control study in RA patients older than 65 years of age showed an increased risk of severe infection that was proportional not only to the current glucocorticoid dosage very but also to the cumulative dosage over 2–3 years [68]. The excess risk of severe infection occurred even with low-dose prednisone therapy (5 mg/day). In addition, two recent studies documented an increase in mortality among patients taking more than 5 mg/day of glucocorticoids [31] and [69]. The task force took into account these data on the efficacy and mid-term safety of glucocorticoid therapy combined with DMARDs. Recommendation #8 supports low-dose prednisone

therapy, in combination with a DMARD, in patients with active RA, most notably early in the course of the disease; but also advises restrictions regarding the dosage and duration of prednisone therapy. A daily dosage of 0.15 mg/Kg can be suggested as a guide but should be tapered as promptly as possible. The maximum treatment duration of 6 months, although not substantiated by strong evidence, nevertheless generated a consensus among the task force members given the data in the literature. Although the cumulative dose is important to consider in individual patients, a strict recommendation applicable to the majority of patients is difficult to develop. An alternative to daily oral glucocorticoid therapy is parenteral methylprednisolone therapy, 80 to 120 mg, which has the advantage of avoiding weaning difficulties [53].