HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi
Part 7 of 8 in Diagnosis and Management of Rheumatoid Arthritis
Managing Severe Flares: Steroid Pulse Therapy and Achieving Sustained Remission
September 1, 2024
A question raised during the session asked about the place of pulse or bolus intravenous corticosteroids (solumedrol) in an acute RA crisis, generalised disabling joint pain with high fever. Dr. Ajmani's answer: steroid pulse therapy can be given in severe RA in patients with many swollen and tender joints, usually methylprednisolone 500mg to 1000mg intravenously once a day for one to three days.
Tapering therapy once remission is reached
Sustained remission, defined as at least 12 months of remission, is the treatment goal before any therapy is decreased. Decreasing steroid and painkiller use is the highest priority once remission is achieved; if a patient is in remission after stopping steroids, the biologic dose can be slowly decreased next, and if remission persists, even the conventional DMARD dose can eventually be reduced.
The value of catching disease early
Dr. Ajmani emphasised that the earliest period of the disease, symptoms present for less than 12 weeks, offers the best window: patients treated in this period had the lowest rate of joint destruction and the highest chance of achieving drug-free remission, meaning the disease course can potentially be altered or completely reversed if treatment starts early enough.
This article is based on a Jivo Masterclass session conducted by Dr. Sajal Ajmani, HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
Looking for a rheumatology consultation or a second opinion? Get in touch with the Jivo team
This guide is based on a live Jivo Masterclass: Dr. Sajal Ajmani taught doctors across Africa on September 1, 2024.
FROM THE LIVE Q&A
Dr. Bafomba
Why does rheumatoid arthritis show a preferential pattern of joint involvement, and why are certain interphalangeal joints spared?
Dr. Sajal Ajmani
DIP (distal interphalangeal) joint involvement is less common in rheumatoid arthritis because there is less synovium in the DIP joints compared to the more commonly affected proximal interphalangeal and metacarpophalangeal joints.
Frequently Asked Questions
What is the place of pulse or bolus intravenous corticosteroids (solumedrol) in an acute crisis of rheumatoid arthritis, generalised disabling joint pain with high fever?▼
Steroid pulse therapy can be given in severe RA in patients with many swollen and tender joints, usually methylprednisolone 500mg to 1000mg intravenously once a day for one to three days.
Beyond the joints, what organs can rheumatoid arthritis affect, particularly the heart, and how is that treated?▼
Extra-articular involvement is rare, but the lungs can develop interstitial lung disease, the eyes can develop scleritis and dryness, the heart very rarely can develop pericarditis and pericardial effusion, the kidneys very rarely can be affected by glomerulonephritis or amyloidosis, and the skin can develop vasculitis. For cardiac involvement specifically, treatment is steroids combined with methotrexate.
What is the recommended medical treatment for palindromic rheumatism?▼
Hydroxychloroquine.
What is the definition of sustained remission?▼
Sustained remission is defined as at least 12 months of remission before any therapy is decreased.
Why does rheumatoid arthritis show a preferential pattern of joint involvement, and why are certain interphalangeal joints spared?▼
DIP (distal interphalangeal) joint involvement is less common in rheumatoid arthritis because there is less synovium in the DIP joints compared to the more commonly affected proximal interphalangeal and metacarpophalangeal joints.
How is a severe acute RA flare treated?▼
With pulse intravenous corticosteroids, usually methylprednisolone 500mg to 1000mg IV once daily for one to three days, in patients with many swollen and tender joints.
What defines sustained remission in RA, and why does early treatment matter?▼
Sustained remission is defined as at least 12 months of remission before tapering therapy. Patients treated within the first 12 weeks of symptoms have the lowest joint destruction and the best chance of drug-free remission.
In This Series: Diagnosis and Management of Rheumatoid Arthritis
- 1.Diagnosis and Management of Rheumatoid Arthritis
- 2.Diagnosing Rheumatoid Arthritis: From the 1987 to the 2010 ACR/EULAR Criteria
- 3.Why Rheumatoid Factor and Anti-CCP Alone Don't Diagnose Rheumatoid Arthritis
- 4.Palindromic Rheumatism and Preclinical RA: Recognising Early and Atypical Presentations
- 5.Monitoring Disease Activity: DAS28, SDAI, CDAI and the ACR Response Criteria
- 6.Treat-to-Target: The EULAR 2016 Recommendations and the DMARD Ladder
- 7.Managing Severe Flares: Steroid Pulse Therapy and Achieving Sustained Remission
- 8.Extra-Articular Rheumatoid Arthritis: Lung, Eye, Heart, Kidney and Skin Involvement