With over 60 years of experience with glucocorticoids (GC), the number of patients treated and the range of clinical applications is more extensive than with other treatments. GC are still widely used in clinical medicine today, and they form a mainstay of therapy for polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) since they are cost-effective drugs which exert strong anti-inflammatory and immunosuppressive.
However, there is increasing awareness of the potential for these drugs to produce adverse effects. Especially if higher dosages have to be given over longer periods of time, cardiovascular, gastrointestinal, dermatological, ophthalmological, and metabolic adverse effects, an increased risk of infection, the incidence of a Cushingoid phenotype, and in particular GC-induced osteoporosis (GIOP) are to be mentioned. The available data describing frequency and severity of these adverse effects are fragmentary. For example, it is difficult to distinguish specific adverse effects of a GC therapy from other causations (e. g., the treated disease itself, other concomitant diseases or concomitant therapies).
Therefore, as a general rule, also in PMR and GCA as much GC as necessary, but as little as possible should be administered. Recommendations and guidelines have been developed describing in detail suggested approaches for using GC in induction therapy, during initial and further tapering until discontinuation, and flare management. It should be noted however, that these algorithms base upon expert opinion and assessment of the literature, but they have not been formally tested in randomized controlled trials.
Treatment of PMR and GCA is usually required for 1–3 years, but frequently also longer and often with daily GC doses around 5 mg prednisone equivalent. Therefore, a recent publication of a EULAR Task Force is important since it reports the risk of harm to be 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.
Disclosure of Interest F. Buttgereit Grant/research support from: Horizon Pharma, Consultant for: Horizon Pharma, Mundipharma, Pfizer, Speakers bureau: Horizon Pharma, Mundipharma, Pfizer