Rheum: Starting prednisone on suspected conditions as initial treatment question

[Nyatar]

Hello, this is my first post. I'm from Chile and I'm in my first year of internship. Once a Rheumatologist told us to not starting prednisone in rheumatoid arthritis suspicion (we don't have access to DMARDs as general practitioners) because at time of referral there will be no objective clinical or laboratory signs of active disease so it would be more difficult to do the differential, so his suggestion was to start only NSAIDs and early referral (although it takes a pair of months here, maybe more).
Following this line of thinking, is there any other conditions where is better not to start prednisone in order to get a better diagnostic prettest?

I hope you could help me, and sorry if there's a lot of grammar

Greetings!

---

Members don't see this ad.

 

[Animalcules]

Hello, this is my first post. I'm from Chile and I'm in my first year of internship. Once a Rheumatologist told us to not starting prednisone in rheumatoid arthritis suspicion (we don't have access to DMARDs as general practitioners) because at time of referral there will be no objective clinical or laboratory signs of active disease so it would be more difficult to do the differential, so his suggestion was to start only NSAIDs and early referral (although it takes a pair of months here, maybe more).
Following this line of thinking, is there any other conditions where is better not to start prednisone in order to get a better diagnostic prettest?

I hope you could help me, and sorry if there's a lot of grammar

Greetings!

This is bad advice. Document tender joints and joints with synovitis, get labs including CRP/ESR, RF, anti-CCP, start prednisone, refer to rheum for DMARD. Time without appropriate treatment is bone lost, early remission and escalating treatment is the key.

 

[Nyatar]

This is bad advice. Document tender joints and joints with synovitis, get labs including CRP/ESR, RF, anti-CCP, start prednisone, refer to rheum for DMARD. Time without appropriate treatment is bone lost, early remission and escalating treatment is the key.

Thanks for your help, I thought that the advice was a strange thing to do so I went here to ask.

 

[drfunktacular]

This is bad advice. Document tender joints and joints with synovitis, get labs including CRP/ESR, RF, anti-CCP, start prednisone, refer to rheum for DMARD. Time without appropriate treatment is bone lost, early remission and escalating treatment is the key.

Agreed. It drives me nuts when I see a new RA patient who's been suffering with active synovitis for 6 weeks prior to seeing me because their PCP "didn't want to mask anything". And as you say, the PCP who didn't want to "mask" anything also seems never to have appropriately documented a detailed musculoskeletal exam

 

[mputman]

I definitely agree with the above, but I would be careful about throwing prednisone at anyone with synovitis. There are plenty of cases I've seen where it would have been better if prednisone hadn't been started. In particular, I recently treated a patient with scleroderma who had gotten prednisone and had a bad outcome and also recently saw a patient with endocarditis who had been misdiagnosed and got prednisone

 

[drfunktacular]

I definitely agree with the above, but I would be careful about throwing prednisone at anyone with synovitis. There are plenty of cases I've seen where it would have been better if prednisone hadn't been started. In particular, I recently treated a patient with scleroderma who had gotten prednisone and had a bad outcome and also recently saw a patient with endocarditis who had been misdiagnosed and got prednisone

It's worth noting that when I do see PCPs start RA patients on prednisone they often use inappropriate doses. Active RA will typically respond very nicely to 5-15mg once daily. You don't need to whack these people with 60mg daily for 6 weeks (which I see fairly often)

5-10mg prednisone for a couple of weeks is not going to have a tremendously negative impact on most disease processes, but obviously if you think a patient has RA but they're RF/CCP-negative you need to re-evaluate your diagnosis very carefully before you go treating them aggressively

Pretty much everyone with scleroderma has a bad outcome

 

[mputman]

It's worth noting that when I do see PCPs start RA patients on prednisone they often use inappropriate doses. Active RA will typically respond very nicely to 5-15mg once daily. You don't need to whack these people with 60mg daily for 6 weeks (which I see fairly often)

5-10mg prednisone for a couple of weeks is not going to have a tremendously negative impact on most disease processes, but obviously if you think a patient has RA but they're RF/CCP-negative you need to re-evaluate your diagnosis very carefully before you go treating them aggressively

Pretty much everyone with scleroderma has a bad outcome

Sadly agree with all the above.