Targeting the time of day for glucocorticoid delivery in rheumatoid arthritis

Glucocorticoid treatment for rheumatoid arthritis is generally taken in the mornings, and there is some evidence to support this practice. However, increased understanding of the role of cytokines in the pathogenesis of rheumatoid arthritis, and of their interaction with the hypothalamic-pituitary- adrenal axis, has suggested that glucocorticoids delivered in the early hours of the morning may have additional efficacy. The development of appropriate tablet technology and the conduct of randomized controlled trials and detailed clinical studies have shown that the early morning increase in plasma IL-6 concentrations, and its associated diurnal increase in symptoms such as morning stiffness can both be reduced by nocturnal glucocorticoid treatment. Fears that hypothalamic-pituitary-adrenal axis responses might be further blunted appear to be unfounded.