Corticosteroids in the Management of Rheumatoid Arthritis

Introduction

Corticosteroids are predominantly used for symptomatic relief of acute pain and inflammation associated with rheumatoid arthritis.[1] Their anti-inflammatory effects are more potent than non-steroidal anti-inflammatory drugs (NSAIDs); however, they have a less desirable side effect profile. Consequently, they are utilized when NSAIDs are not adequately managing acute symptoms.[1]

Mechanism of Action

Corticosteroids modulate gene expression by binding to glucocorticoid receptors. Specifically, they promote the up-regulation of anti-inflammatory genes and down-regulation of pro-inflammatory genes. This inhibits the inflammatory effects of circulating monocytes and eosinophils, thus contributing to relief of acute symptoms.[2]

The half life of corticosteroids ranges from less than 20 minutes to up to 120 minutes for large steroid loads. Elimination rates vary greatly, ranging from 15-200 mg per day.[2]

Clinical Implications

Common adverse effects of corticosteroids include immunosuppression, steroid-induced diabetes and osteoporosis, muscle weakness, thin skin, easy bruising, hypertension, edema, and hypokalemia.[3] Several of these side effects are of particular note for the physical therapist (PT). Immunosuppression may lead to increased incidence of infection; the PT should follow proper infection control protocol between patients including sanitation of all surfaces and hands. Osteoporosis is a contraindication for several physical therapy interventions, so PTs must proceed with caution when selecting treatments and modalities. Reference this page for physical therapy management of osteoporosis. If signs of developing osteoporosis or diabetes are noted, the PT should notify the patient's primary care physician. Due to easy bruising and thin skin, PTs should ensure that they are monitoring skin integrity of the patient at each session. When assessing muscle strength, be aware that weakness may be due to corticosteroid treatment. PTs should be taking vitals every session in order to monitor for hypertension secondary to corticosteroid use.

References

  1. 1.0 1.1 Singh JA, Saag KG, Bridges SL, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care Res. 2016;68(1):1-25. doi:10.1002/acr.22783.
  2. 2.0 2.1 McKay LI, Cidlowski JA. Pharmacokinetics of Corticosteroids. In: Holland, JF, Frei E, et al, ed.Cancer Medicine. 6th ed. Hamilton, ON: BC Decker, Inc;2003.
  3. Bingham, C. John Hopkins University. Rheumatoid arthritis treatment. https://www.hopkinsarthritis.org/arthritis-info/rheumatoid-arthritis/ra-treatment/. Accessed October 3, 2018.
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