Should oral glucocorticoids be used empirically now to suppress the presumed RA?
While it is appropriate to make a diagnosis of RA in this woman, it is not appropriate to begin oral glucocorticoids unless there is a definitive plan to discontinue them relatively soon. Such a plan, used by many rheumatologists, has received credence from the BeSt study, a randomized trial designed to compare targeted treatment strategies.(7) The results—reaching a low disease activity score—were obtained with two protocols: (a) initial combination therapy with methotrexate, sulfasalazine, and rapidly tapered high-dose prednisone therapy, and (b) initial combination therapy with methotrexate and infliximab (a monoclonal antibody directed against tumor necrosis factor [TNF] alpha). Patients on either of these two regimens were more likely to achieve a clinical remission of disease and to have significantly less joint damage progression after 2 years than those on either sequential monotherapy or step-up to combination therapy. Those on the protocol that included initial prednisone did
