Prednisone in rheumatoid arthritis: metabolic and clinical effects.

The initial reports (Hench, Kendall, Slocumb, and Polley, 1949; Sprague, Power, Mason, Albert, Mathieson, Hench, Kendall, Slocumb, and Polley, 1950; Hench and others, 1950) of the antirheumatic potency of cortisone emphasized the fact that excessive doses produced not only desirable but also certain undesirable effects. At that time (1949), we expressed our hope and belief that analogues superior to cortisone would be discovered. Since then, at least seven more cortisone-like steroids have been found useful clinically; these include hydrocortisone, 9-alpha-fluorohydrocortisone (Fludrocortisone), prednisone, prednisolone, a compound whose structure is 9-alpha-fluoro, delta 1-hydrocortisone, and the two most recent additions, namely triamcinolone and 6-methyl, delta I-hydrocortisone. Each of these eight compounds has distinctive characteristics. Cortisone is the least costly to prepare synthetically; it is still useful in many cases and preferable in some. Hydrocortisone, apparently the major product of the normal human adrenal cortex, has proved to be superior to cortisone in local, especially intra-articular, administration. Fludrocortisone possesses a greatly enhanced antirheumatic effect (about ten times greater than that of cortisone, milligram for milligram); however, its effect on the retention of sodium and chloride and the excretion of potassium is even more enhanced. Thus, fludrocortisone is especially useful in the adrenal insufficiency of Addison's disease and when used in ointments for certain dermatological conditions, but the qualities that make it superior to cortisone or hydrocortisone in the management of Addison's disease interfere with its usefulness for rheumatic patients. Nevertheless, its production represented a distinct advance, because it demon-