With over 60 years of experience with glucocorticoids (GC), the number of patients treated and the range of clinical applications is extensive, and GC are still widely used in clinical medicine today. For example, they form a mainstay of therapy for rheumatoid arthritis (RA) since they are cost-effective drugs that exert strong anti-inflammatory, immunosuppressive and disease-modifying therapeutic effects.
However, the potential of GC to produce adverse effects may prompt both patients and prescribing doctors to take a critical view on these important drugs. As with all diagnostic and therapeutic approaches in medicine, the primary aim is a positive benefit:risk ratio when using these important drugs. In clinical medicine, this means that it is clearly wrong not to treat conditions such as an active giant cell arteritis or a flare of systemic lupus erythematosus, which clearly benefit from this drug. On the other hand, it is equally wrong to make use of GC when not indicated or to use them at doses that are higher than required or for longer duration than necessary.
Consequently, this increasing awareness of the potential adverse effects suggests that the improvement of GC benefit:risk ratio represents both a current need and an ongoing challenge. The developing and detailed knowledge of mechanisms of GC action has resulted in exploration of numerous approaches to optimize treatments with these important drugs. All these approaches ultimately aim to answer one underlying salient question: How can we optimize treatments with GC?
It is important to establish the sensible approaches in order to reach this aim. There are essentially three viable approaches currently available:
(1) Improvement of current guidelines and recommendations on optimal use of these drugs based on existing knowledge.
(2) Clinical trials conducted to determine optimal use of GC treatment (such as in combination with disease-modifying antirheumatic drugs).
(3) Development of novel, improved GC drugs (such as a chronotherapeutic formulation of prednisone (termed modified- or delayed-release prednisone), dissociated agonists of GC receptor (DAGR), or so called liposomal GC).
Disclosure of Interest F. Buttgereit Grant/research support from: Horizon Pharma, Consultant for: Horizon Pharma, Mundipharma, Pfizer, Speakers bureau: Horizon Pharma, Mundipharma, Pfizer