How do Rheumatologists Feel About Prescribing Glucocorticoids?

While glucocorticoids (GCs) are an integral part of the treatment and management of rheumatic diseases, rheumatologists have reduced the prescription of GCs due to safety issues and side effects, especially for patients on a long-term treatment plan and those receiving higher doses. Recently, the American College of Rheumatology (ACR) guidelines have stressed minimizing GC treatment in both adult and pediatric patients within the last year, as previously covered by Rheumatology Network.

Intraarticular glucocorticoid injections, for example, are a mainstay of treatment for oligoarticular juvenile idiopathic arthritis (JIA) and intravenous steroids can be lifesaving for these patients. However, daily steroids are not a replacement for disease-modifying antirheumatic drugs (DMARDs) when available and appropriate. Rheumatologists focus on minimizing diease activity while also preventing damage to optimize health-related quality of life in their patients.

Further, although there is no clear association between rheumatic disease and an increased risk of hospitalization or death after developing COVID-19, research indicates that patients receiving glucocorticoids were more likely to have worse outcomes, even at lower doses.

However, a low dose of prednisone, as a first line monotherapy, was shown to improve symptom severity and disease activity in patients with newly diagnosed rheumatoid arthrits.

In the interest of receiving a variety of opinions from rheumatologists, we asked several key opinion leaders about their thoughts on treating patients with GCs, regarding their reputation, benefits, risks, and if they are ultimately more helpful or harmful in the treatment of rheumatic diseases.

Jeffrey Stark, MD

Jeffrey Stark, MD

UCB

Steroids certainly have a place in the clinical care of patients and are an important tool. Unfortunately, what we find for many inflammatory disease states is that patients are treated with corticosteroids over a long period of time or received corticosteroids in a way that is less than optimal. The answer depends somewhat on the disease state. For example, we can say that topical corticosteroids may be helpful for patients living with plaque psoriasis who use steroid treatments topically on their areas of involved skin. However, systemic corticosteroids, given orally or by an intramuscular injection, have very little role in the treatment of plaque psoriasis and can sometimes even provoke a rebound reaction where the psoriasis worsens as patients try to come off those steroids.

In the arthritic disease states, like psoriatic arthritis or axial spondyloarthritis, corticosteroids injected in an inflamed joint may be helpful to treat that 1 joint by putting steroids directly where the inflammation is. However, once again, the use of steroids, like oral steroids, have little or no role in the treatment of those conditions. For example, when we see a patient who's on systemic steroids taking prednisone by mouth over long periods of time, I think we must always ask ourselves is if there is something better that this patient could be treated with that would eliminate their need to take those corticosteroids. The reason we're concerned about that is not just because they're not recommended, but in fact, corticosteroids have long-term side effects, including weight gain, diabetes, osteoporosis, and cataracts, that we certainly don't want any of our patients to experience if they're avoidable.

Joyce Chang, MD, MSCE

Joyce Chang, MD, MSCE

Boston Children’s Hospital

It’s the biggest love hate relationship we have. In the beginning, to achieve disease control, we sometimes have to use glucocorticoids, although we don't like to do that. But when you're trying to put out a fire, sometimes you just have to “dump buckets of water on it.”I do think, however, we now have access to a lot of other medicines that are steroid-sparing. We're learning to be more aggressive with those alternative therapies so that we can really reduce glucocorticoid exposure in our kids.

A lot of kids get lupus when they're preteens or teenagers and some of the cosmetic side effects of steroids are so detrimental to their mental health. Adults have enough problems dealing with that, but then to be a teenager, still trying to develop your self-identity, and then on top of that having to deal with issues and side effects from medicines, weight gain, changes in appearance, and acne, is difficult. As rheumatologists, we worry more about bone health, avascular necrosis, and those types of things with steroids, but I don't think we intentionally pay enough attention to the psychology of steroids. I do think that moving forward will be focused on standardizing how we use other steroid-sparing treatments that we can do better in that regard.

Shanthini Kasturi, MD, MS

Shanthini Kasturi, MD, MS

Tufts Medical Center, Tufts University School of Medicine

It's an important topic because we've seen the toxicity that steroids can have over time, especially the longer you're on them and the higher dose that patients are exposed to. Context really matters because sometimes a patient needs treatment quickly and the only thing that works quickly are glucocorticoids. But the most important thing we are realizing is that even if you need to use steroids in the short term, we must limit that use so that it doesn't become a long-term treatment. We need move to steroid-sparing treatments as soon as we can. We try to minimize the exposure because we want to avoid these side effects. So, while context matters, there is a role for steroids right now since sometimes they're the fastest thing that can help, especially in lupus.