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*For medical professionals to read for reference only.
For most patients with RA, the risk of injury is low at a long-term dose of ≤5mg prednisone per day
.
From September 17 to 19, 2021, the 13th International Forum on Rheumatoid Arthritis was successfully held in Beijing
.
Professor Li Hongbin from the Department of Rheumatology and Immunology, Affiliated Hospital of Inner Mongolia Medical University, brought the topic "Application of Glucocorticoids in the Treatment of Rheumatoid Arthritis-Re-discussion in 2021"
.
The advantages and disadvantages of glucocorticoid (GC), a classic drug in rheumatoid arthritis (RA), are elaborated and analyzed in detail
.
Picture: Professor Li Hongbin speaking in the forum 1.
GC treatment of RA: subjective or objective effect? Previous studies have focused on whether GC can achieve the objective effects of improving the condition of anti-rheumatic drugs (DMARDs), including relief of clinical symptoms, long-term inhibition of bone erosion damage and preservation of joint function, thereby improving the prognosis
.
A retrospective study of low-dose GC monotherapy inducing remission of newly diagnosed RA showed that [1], short-term use of low-dose prednisone monotherapy can induce disease remission and improve the clinical severity of RA in most newly diagnosed patients
.
The results of the Dutch multi-center CAMERAII study showed that [2] adding low-dose prednisone to the treatment strategy based on methotrexate (MTX) to strictly control early RA can improve the prognosis of patients
.
The results of a randomized controlled trial found that, compared with the initial sulfasalazine (SSZ) monotherapy, the initial COBRA combination therapy numerically reduced mortality and similar comorbidities
.
In addition, lower joint damage progression indicates long-term disease changes
.
Figure 1: COBRA combination treatment plan So, with the blessing of GC, do you need a combination of multiple traditional synthetic DMARDs (csDMARDs)? The CareRA study [3] gave the answer: all DMARDs combined with GC are effective for early RA patients for up to 2 years
.
Regardless of the patient's prognosis, MTX monotherapy bridging GC and COBRA-Slim regimen (MTX, prednisone decreasing from 30mg) can provide the best balance between efficacy and safety
.
Therefore, the application of small doses of GC in RA is safe and effective
.
2.
GC should be reduced: how to do it? However, Professor Li Hongbin pointed out that the special mechanism of GC may make it difficult for humans to retreat
.
Studies have shown that GC treatment changes and modulates approximately 1% of the human genome [4]
.
Based on concerns about GC, the 2016 European Union Against Rheumatism (EULAR) [5] recommends the minimum dose of GC (not more than 6 months) as an adjuvant treatment
.
But how do you reduce the volume, and what is the effect of the volume reduction? Studies have found [6] that it is difficult for patients receiving low-dose GC treatment to successfully reduce the stop, and 58% of patients have increased disease activity during the reduction process
.
The study believes that low-dose GC treatment after a few years has a sustained anti-inflammatory effect on RA and has no further negative effects on bone mineral density (BMD)
.
Therefore, considering bone health, controlling disease activity in this population seems to be more important than stopping low-dose GC treatment
.
An earlier study published in The Lancet also concluded that [7] 71.
5% of RA patients cannot reduce the dose or stop the GC to maintain remission, and those with GC treatment less than 5 years are more likely to successfully reduce the dose
.
Only one patient in the successful reduction can reduce the dose at a rate of 1mg/3.
5m and maintain remission
.
Therefore, for the GC use time recommendation proposed in the EULAR guidelines, Professor Li Hongbin believes that "ideal is very full, reality is very skinny"
.
In addition, Professor Li Hongbin also emphasized that at present, some doctors or patients are overly worried about the side effects of GC and dare not use it, but in fact, for most RA patients, the risk of injury is low at a long-term dose of ≤5mg prednisone per day.
; When the dose is more than 10mg/day, the risk of injury will increase [8]
.
3.
The possibility of GC freedom? Professor Li Hongbin believes that the current possible options for realizing the freedom of GC treatment for RA patients include: changing RA treatment strategies: achieving rapid, effective and comprehensive induction and remission of new innovative GC pharmacoeconomics.
Some scholars have proposed whether the inclusion of biological agents in the first-line treatment will improve How is GC used? According to the results of the IDEA study [9], in patients with early RA who did not receive DMARDs, the initial treatment of MTX + high-dose intravenous steroids can achieve good disease control with little structural damage
.
However, MTX+infliximab (IFX) is not statistically superior to MTX+ intravenous steroids
.
There are also studies that [10], the simultaneous use of GC and tofacitib (a JAK inhibitor) does not seem to affect clinical or radiological efficacy
.
MTX+GC showed a tendency to inhibit the progress of radiology to a greater extent than using MTX alone
.
In addition, Professor Li Hongbin proposed that better GCs are under development, including sustained-release hormones, glucocorticoid liposomes, selective glucocorticoid receptor agonists, free glucocorticoid agonists and selective glucocorticoid receptors.
regulatory agent
.
Finally, Professor Li Hongbin emphasized that in order to have a free treatment plan for GC, 4Ps are needed: Please: Doctors must be patient and patient with patients: Patients need to be patient enough to endure (Pain): Patients must learn to be patient Presence: The effect of the drug needs to be waited.
References: [1]Adv Rheumatol.
2021 Aug 9;61(1):50.
[2]Ann Intern Med.
2012;156:329-339[3]Rheumatology(Oxford ).
2019 Dec 1;58(12):2284-2294.
[4]Nat Rev Rheumatol.
2020 Apr;16(4):239-245.
[5]Ann Rheum Dis.
2016.
79;685-699.
[6] Scand J Rheumatol.
2007;36(5):351-358.
[7]Lancet.
1996:2(7470):935-937.
[8]Ann Rheum Dis.
2016;75:952-957.
[9]Ann Rheum Dis.
2014;73:75-85.
[10]J Rheumatol.
2018 Feb;45(2):177-187.
For most patients with RA, the risk of injury is low at a long-term dose of ≤5mg prednisone per day
.
From September 17 to 19, 2021, the 13th International Forum on Rheumatoid Arthritis was successfully held in Beijing
.
Professor Li Hongbin from the Department of Rheumatology and Immunology, Affiliated Hospital of Inner Mongolia Medical University, brought the topic "Application of Glucocorticoids in the Treatment of Rheumatoid Arthritis-Re-discussion in 2021"
.
The advantages and disadvantages of glucocorticoid (GC), a classic drug in rheumatoid arthritis (RA), are elaborated and analyzed in detail
.
Picture: Professor Li Hongbin speaking in the forum 1.
GC treatment of RA: subjective or objective effect? Previous studies have focused on whether GC can achieve the objective effects of improving the condition of anti-rheumatic drugs (DMARDs), including relief of clinical symptoms, long-term inhibition of bone erosion damage and preservation of joint function, thereby improving the prognosis
.
A retrospective study of low-dose GC monotherapy inducing remission of newly diagnosed RA showed that [1], short-term use of low-dose prednisone monotherapy can induce disease remission and improve the clinical severity of RA in most newly diagnosed patients
.
The results of the Dutch multi-center CAMERAII study showed that [2] adding low-dose prednisone to the treatment strategy based on methotrexate (MTX) to strictly control early RA can improve the prognosis of patients
.
The results of a randomized controlled trial found that, compared with the initial sulfasalazine (SSZ) monotherapy, the initial COBRA combination therapy numerically reduced mortality and similar comorbidities
.
In addition, lower joint damage progression indicates long-term disease changes
.
Figure 1: COBRA combination treatment plan So, with the blessing of GC, do you need a combination of multiple traditional synthetic DMARDs (csDMARDs)? The CareRA study [3] gave the answer: all DMARDs combined with GC are effective for early RA patients for up to 2 years
.
Regardless of the patient's prognosis, MTX monotherapy bridging GC and COBRA-Slim regimen (MTX, prednisone decreasing from 30mg) can provide the best balance between efficacy and safety
.
Therefore, the application of small doses of GC in RA is safe and effective
.
2.
GC should be reduced: how to do it? However, Professor Li Hongbin pointed out that the special mechanism of GC may make it difficult for humans to retreat
.
Studies have shown that GC treatment changes and modulates approximately 1% of the human genome [4]
.
Based on concerns about GC, the 2016 European Union Against Rheumatism (EULAR) [5] recommends the minimum dose of GC (not more than 6 months) as an adjuvant treatment
.
But how do you reduce the volume, and what is the effect of the volume reduction? Studies have found [6] that it is difficult for patients receiving low-dose GC treatment to successfully reduce the stop, and 58% of patients have increased disease activity during the reduction process
.
The study believes that low-dose GC treatment after a few years has a sustained anti-inflammatory effect on RA and has no further negative effects on bone mineral density (BMD)
.
Therefore, considering bone health, controlling disease activity in this population seems to be more important than stopping low-dose GC treatment
.
An earlier study published in The Lancet also concluded that [7] 71.
5% of RA patients cannot reduce the dose or stop the GC to maintain remission, and those with GC treatment less than 5 years are more likely to successfully reduce the dose
.
Only one patient in the successful reduction can reduce the dose at a rate of 1mg/3.
5m and maintain remission
.
Therefore, for the GC use time recommendation proposed in the EULAR guidelines, Professor Li Hongbin believes that "ideal is very full, reality is very skinny"
.
In addition, Professor Li Hongbin also emphasized that at present, some doctors or patients are overly worried about the side effects of GC and dare not use it, but in fact, for most RA patients, the risk of injury is low at a long-term dose of ≤5mg prednisone per day.
; When the dose is more than 10mg/day, the risk of injury will increase [8]
.
3.
The possibility of GC freedom? Professor Li Hongbin believes that the current possible options for realizing the freedom of GC treatment for RA patients include: changing RA treatment strategies: achieving rapid, effective and comprehensive induction and remission of new innovative GC pharmacoeconomics.
Some scholars have proposed whether the inclusion of biological agents in the first-line treatment will improve How is GC used? According to the results of the IDEA study [9], in patients with early RA who did not receive DMARDs, the initial treatment of MTX + high-dose intravenous steroids can achieve good disease control with little structural damage
.
However, MTX+infliximab (IFX) is not statistically superior to MTX+ intravenous steroids
.
There are also studies that [10], the simultaneous use of GC and tofacitib (a JAK inhibitor) does not seem to affect clinical or radiological efficacy
.
MTX+GC showed a tendency to inhibit the progress of radiology to a greater extent than using MTX alone
.
In addition, Professor Li Hongbin proposed that better GCs are under development, including sustained-release hormones, glucocorticoid liposomes, selective glucocorticoid receptor agonists, free glucocorticoid agonists and selective glucocorticoid receptors.
regulatory agent
.
Finally, Professor Li Hongbin emphasized that in order to have a free treatment plan for GC, 4Ps are needed: Please: Doctors must be patient and patient with patients: Patients need to be patient enough to endure (Pain): Patients must learn to be patient Presence: The effect of the drug needs to be waited.
References: [1]Adv Rheumatol.
2021 Aug 9;61(1):50.
[2]Ann Intern Med.
2012;156:329-339[3]Rheumatology(Oxford ).
2019 Dec 1;58(12):2284-2294.
[4]Nat Rev Rheumatol.
2020 Apr;16(4):239-245.
[5]Ann Rheum Dis.
2016.
79;685-699.
[6] Scand J Rheumatol.
2007;36(5):351-358.
[7]Lancet.
1996:2(7470):935-937.
[8]Ann Rheum Dis.
2016;75:952-957.
[9]Ann Rheum Dis.
2014;73:75-85.
[10]J Rheumatol.
2018 Feb;45(2):177-187.
