Introduction

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by recurrent episodes of joint inflammation and systemic manifestations. Despite major advances in biologic therapies, glucocorticoids (GCs) remain widely used because of their rapid anti-inflammatory effects and their role as bridging therapy during the initiation or adjustment of disease-modifying antirheumatic drugs (DMARDs). However, prolonged exposure to GCs is associated with substantial morbidity, including osteoporosis, cardiovascular disease, diabetes mellitus, and an increased risk of infections [1,2].

The 2022 update of the European League Against Rheumatism (EULAR) recommendations strongly emphasizes that GCs should be prescribed for the shortest duration possible, particularly during the early phase of conventional synthetic DMARD (csDMARD) initiation, and tapered as rapidly as clinically feasible [3]. In patients achieving sustained remission, as assessed by validated composite measures of disease activity (Disease Activity Score in 28 joints (DAS28)), GCs should be discontinued before considering tapering of biologic DMARDs (bDMARDs) or csDMARDs [3].

Despite these recommendations, discontinuation of GCs remains challenging in routine clinical practice. Real-world studies have shown that nearly half of patients treated with bDMARDs, including tumor necrosis factor inhibitors (anti-TNF) and rituximab, continue low-dose prednisone for more than six months after biologic initiation [4-6]. Moreover, the commonly accepted threshold defining “low-dose” GC therapy (≤7.5 mg/day) remains largely arbitrary and does not correspond to a clearly established threshold of efficacy or safety [7].

GC tapering is further complicated by the unpredictable risk of disease flare, which may occur even in patients with sustained disease control [8,9]. Although approximately 50% of patients with early RA can discontinue GCs within three years, up to 30% experience disease flare during the first six months following withdrawal [10]. These findings emphasize the need to better define GC tapering strategies and to identify predictors of successful GC withdrawal, particularly in patients receiving biologic therapies such as rituximab or anti-TNF agents.

A daily prednisone dose of 5 mg represents a clinically meaningful threshold in RA and is frequently used as a maintenance dose in patients with controlled disease. The SEMIRA trial [11] showed that maintaining prednisone at 5 mg/day provided better disease control than complete GC withdrawal. In contrast, the GLORIA trial [12] demonstrated that even this low dose remained associated with treatment-related adverse events. Therefore, achieving a prednisone dose of ≤5 mg/day may be considered a pragmatic GC-sparing target while recognizing that complete withdrawal remains the ultimate goal. TNF inhibitors and rituximab are among the most widely used biologic therapies for RA. However, few studies have directly compared their GC-sparing effects.

The present study aimed to evaluate GC tapering in patients with RA initiating biologic therapy and to assess the effectiveness of biologic agents in achieving GC-sparing outcomes in routine clinical practice.