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14 Articles in Volume 21, Issue #5
Analgesics of the Future: Interleukin-17 Inhibitors for Treating Psoriatic Arthritis
Ask the PharmD: What evidence exists for metformin in treating rheumatoid arthritis pain?
Case Chat: Spasms vs. Spasticity and Muscle Relaxant Options
CDC Opioid Prescribing Guideline Updates Are in the Works: Will the Changes be Enough?
Chronic Pain Management in Marginalized Populations: How to Rebalance the Provider-Patient Relationship
Dantrolene: The Forgotten Molecule for Outpatient Spasticity
Forgotten Analgesics: The Drugs Pain Practitioners Need to Reconsider
Machine Learning Predicts Patient Response to Rheumatoid Arthritis Therapy
Perspective: Where Have All the Rheumatologists Gone?
Rheumatoid Arthritis and Bridge Therapy: Primary Care Considerations
Root Cause of Plantar Fasciitis: Three-Step Exercise Protocol
Shoulder Pain and Rotator Cuff Injuries: Emerging Treatments
Special Report: The Evolution of Rheumatoid Arthritis Treatment, from Gold to Gene Therapy
Transfer of Care: Barriers and Solutions in Chronic Pain Management

Rheumatoid Arthritis and Bridge Therapy: Primary Care Considerations

Steroids should be limited when treating RA, but there are times when their use may be necessary. Here’s how to weigh treatment options according to the ACR.

with Joel M. Kremer, MD, Don L. Goldenberg, MD, and Liana Fraenkel, MD

Bridge therapy – the use of steroids as a temporary treatment for individuals diagnosed with rheumatoid arthritis (RA) who are in pain – has been talked about for 20-plus years, and especially for recently diagnosed patients. In recent years, however, new research has fostered better understanding of this approach, leading to recommends limits on steroid use.

Bridge therapy for rheumatoid arthritis “should be looking at getting the patient to less than 5 mg a day in a matter of weeks,” notes Dr. Kremer. (Image: iStock)

 

Bridge Therapy for Rheumatoid Arthritis: A Clinical Refresher

For decades, researchers have investigated oral steroids as bridge therapy. One study published in 1995 in Rheumatology evaluated 40 individuals with rheumatoid arthritis, randomized to receive prednisone or placebo for 18 weeks, with the initial dose of 10 milligrams a day tapered to 2.5 mg. But after tapering, a rebound deterioration was noticed in more than half of the subjects, with the researchers concluding that the dose-reduction scheme is not recommended.1

In an update on glucocorticoids in RA management, published in 2020, the researchers noted that glucocorticoids have been a substantial part of the therapeutic arsenal for rheumatoid arthritis since their use began in the late 1940s. However, their toxicity remains a topic of controversy. The authors pointed out that both the European League Against Rheumatism (EULAR) and the ACR advocate for the use of glucocorticoids as adjunct treatment to conventional synthetic disease modifying antirheumatic drugs (DMARDs) at the lowest dose possible for the shortest time possible.

These researchers also suggested further research on low-dose versus very low-dose glucocorticoids and the exact optimal duration of bridge therapy. Even low doses can have toxicity and, for that reason, EULAR recommends using the lowest possible dose for the least amount of time, focusing on a 5 mg daily limit.2

One approach that has been suggested is called COBRA-Slim, with methotrexate given plus 30 mg of prednisone tapered, so the patient is down to  5 mg a day by week 6. In a study that compared this approach to methotrexate only, individuals on the combination had lower disease activity scores (DAS) and lower disability and pain scores. Researchers say the COBRA-Slim approach also reduces the risk of chronic NSAID and analgesic use in early methotrexate-treated RA, which can cause side effects such as constipation, diarrhea, and dizziness.3-5

 

Bridge Therapy for RA: Pros and Cons

The term ‘‘bridge therapy” has never sat well with Joel M. Kremer, MD, a rheumatologist and the Pfaff Family Professor of Medicine at Albany Medical College, Albany, NY. He dislikes the whole metaphor of a bridge, he tells PPM. “It’s like you are going over a challenging period,” he says,and then the thinking is often: “We get them over this challenging period, and they will be in the promised land of doing well with their disease.”

The problem? “The bridge became an interstate that took you from one ocean to another,” Dr. Kremer explains. “Patients felt too good taking it. You could lower the dose but never eliminate it.” And he says he often would hear physicians ask:  ‘‘Well, what’s the harm?”

Guidelines on Treating Rheumatoid Arthritis

There definitely are harms, shares Dr. Kremer, and the latest guidelines on management of rheumatoid arthritis from the American College of Rheumatology (ACR) back him up. In the latest version, ACR discourages the use of so-called bridge therapy. “The recommendation is now conditionally against using low-dose prednisone for bridge therapy – but the recommendation is conditional, recognizing that many patients will still require prednisone until DMARDs kick in,” adds Liana Fraenkel, MD, lead author of the new guideline and a rheumatologist at Yale University.

In the 2021 ACR guidelines, methotrexate is stressed as a cornerstone therapy for rheumatoid arthritis. In addition, the guidelines say glucocorticoids should not be “systematically prescribed,” although the recommendation is conditional since the medications are often needed to improve symptoms before DMARDs’ onset of action. And if bridge therapy is considered necessary to control symptoms, clinicians should give the lowest possible dose of steroids for the shortest duration, according to the guidelines.

Treating Rheumatoid Arthritis When a Rheumatologist Isn’t Available

Another challenge with RA treatment is that, while pain specialists and primary care providers (PCPs) are likely – and encouraged – to refer people with RA to a rheumatologist for specialty care, a timely referral to a specialist may not be possible, given the shortage of rheumatologists in the US.

In 2015, the ACR Workforce Study predicted that by 2030, adult rheumatology providers (physicians, nurses, and others) would decline by 25% as the number of patients with RA rises, resulting in demand exceeding supply by 102%.6 Thus, the non-rheumatologist physician may need to explain (and prescribe, for a brief time) bridge therapy to patients living with rheumatoid arthritis. Don L. Goldenberg, MD, discusses this shortage in a related article. Dr. Goldenberg is an emeritus professor of medicine at the Tufts University School of Medicine, and an adjunct faculty member in the Department of Medicine and Nursing at Oregon Health & Science University, Portland.

As a result, it’s important that all providers understand the pros and cons of bridge therapy.

What Rheumatologists Say about Steroids for RA: Practical Takeaways

There is a role for prescribing glucocorticoids, argues Dr. Goldenberg, such as while a PCP or a pain specialist is waiting for an appointment referral to a rheumatologist. “PCPs should feel comfortable to prescribe [prednisone] in a person with suspected or definitive RA for a brief period of time [while] waiting for the next step.”

“A low dose for 2, 4, 6 weeks is very safe,” he says, and he views it as a better approach than pushing NSAIDs. “The key is, the shorter the bridge the better. The quicker you can see the rheumatologist and get on definitive therapy the better, whether it’s methotrexate or the newer biologic agents.”

“I think we are in better shape treating RA than we have ever been,” adds Dr. Kremer. He points to ‘‘excellent biologics” such as the JAK inhibitors. “They work quicky. You can see clear effects in a week or two. They’re really good but nowhere near the life-altering effect of the high-dose steroids.”

Dr. Kremer agrees. “You really have to use the lowest [steroid] dose possible for the lowest amount of time.” Yet, he also agrees that ‘‘there are times you simply have to use steroids.”The high-dose steroids, he explains, ‘‘will get you from bed to the garden to the tennis court in two days.” And some patients like that speed, but he reminds them of the potentially bad side effects and the dependency issues.

Bridge therapy, Dr. Kremer says, if used, “should be looking at getting the patient to less than 5 mg a day in a matter of weeks.”

Consider the Long Treatment Plan for RA

Finally, Dr. Kremer urges all physicians to take the long view when caring for RA patients, taking into account effectiveness and sides effects, among other factors. “We’ve all seen the horror stories, patients who have been on steroids for 8 or 10 years. They have diabetes, hypertension, their limbs are weak.” He urges physicians to remember this when treating an RA patient: “These people have a lifelong disease. It’s not like they have just broken a finger or sprained a limb.”

See also, a commentary on the US rheumatology shortage.

Last updated on: September 8, 2021
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