Although there is convincing evidence for the beneficial effects of glucocorticoids at low dosages to treat rheumatoid arthritis and other rheumatic diseases, the potential harms lead patients and physicians to be grouped as glucocorticoid “supporters”, “opponents” or “neutrals” (i.e. people not favouring any pro or con position, perhaps the majority). In detail, patients are usually aware of both benefits and risks of glucocorticoid therapy. There is, however, sometimes even a certain imbalance favouring the risks over the benefits. This may be reflected in serious concerns about adverse effects and sometimes even refusal to take glucocorticoid treatment which hinders optimal treatment. Also with regard to medical doctors, nobody really questions the efficacy of these drugs, but the splitting up into the mentioned groups is primarily driven by safety concerns. And indeed, every group has their good arguments.
To approach this problem, a EULAR Task Force was convened in order to achieve consensus on specific conditions where long-term glucocorticoid therapy has an acceptably low risk of harm in the treatment of chronic inflammatory rheumatic diseases (Strehl et al., Ann Rheum Dis, 2016). After a systematic literature search, the evidence on the four most worrisome adverse effects of glucocorticoid therapy (osteoporosis, hyperglycaemia/diabetes mellitus, cardiovascular diseases, and infections) was critically reviewed. Robust evidence on the risk of harm of long-term glucocorticoid therapy was often lacking since relevant study results were often either missing, contradictory, or at a high risk of bias. The group agreed that the risk of harm is low for the majority of patients at long-term dosages of ≤5mg prednisone equivalent per day, whereas at dosages of >10mg/d the risk of harm is elevated. At dosages between >5 and ≤10mg/d, patient-specific characteristics including protective and/or risk factors need consideration when estimating the risk of harm.
In conclusion, the level of harm of glucocorticoids depends on both dose and patient-specific parameters. General, disease and glucocorticoid associated risk factors but also protective factors like a healthy lifestyle should be taken into account when evaluating the actual and future risk.
Disclosure of Interest F. Buttgereit Grant/research support from: Horizon Pharma, Consultant for: Horizon Pharma, Mundipharma, Pfizer, Speakers bureau: Horizon Pharma, Mundipharma, Pfizer