A RECENT trial, known as the STAR study, compared two glucocorticoid tapering strategies in patients with rheumatoid arthritis (RA) in low disease activity (LDA) and found no significant difference in the success rates of discontinuing glucocorticoids. The study aimed to determine whether a hydrocortisone replacement approach or a prednisone tapering strategy would more effectively support patients in stopping glucocorticoid therapy, a critical step in reducing long-term side effects associated with these medications.
This double-blind, randomised controlled trial included 102 RA patients, all of whom had been receiving a stable glucocorticoid dose of 5 mg per day for at least three months and had maintained LDA for the same duration. Participants were randomly assigned to one of two groups: one group gradually replaced prednisone with hydrocortisone over six months before complete discontinuation, while the other group tapered prednisone by reducing the dose by 1 mg per month until complete discontinuation. The primary outcome was the proportion of patients who successfully discontinued glucocorticoids at 12 months.
Results showed that 55% of patients in the hydrocortisone group and 47% in the prednisone tapering group achieved successful glucocorticoid discontinuation after 12 months, with no significant difference between the groups. Both strategies maintained similar levels of disease control, with no notable differences in flare rates, additional glucocorticoid needs, disease activity, or patient-reported outcomes. Importantly, no cases of acute adrenal insufficiency were reported in either group, although 17 patients had abnormal adrenocorticotropic hormone (ACTH) stimulation test results, indicating some level of adrenal impairment, with no difference observed between the groups.
These findings suggest that both tapering approaches are viable for patients with RA in LDA who wish to discontinue glucocorticoids, providing flexibility for clinicians in selecting the best approach based on individual patient needs. The study highlights the importance of tailored glucocorticoid tapering strategies in managing RA, allowing patients to safely reduce or discontinue glucocorticoid use without compromising disease control.
Reference
Ruyssen-Witrand A et al. Comparison of two strategies of glucocorticoid withdrawal in patients with rheumatoid arthritis in low disease activity (STAR): a randomised, placebo-controlled, double-blind trial. Ann Rheum Dis. 2024; DOI: 10.1136/ard-2024-226620.
