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Glucocorticoids in rheumatoid arthritis: the picture is shaping up
  1. Frank Buttgereit1,
  2. Johannes W Bijlsma2
  1. 1Department of Rheumatology and Clinical Immunology, Charité—University Medicine Berlin, Berlin, Germany
  2. 2Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
  1. Correspondence to Professor Frank Buttgereit, Department of Rheumatology and Clinical Immunology, Charité – University Medicine Berlin, 10117 Berlin, Germany; frank.buttgereit{at}charite.de

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Despite the well-known efficacy of glucocorticoids (GCs), it is more common than exceptional that their known adverse event profile and co-morbidity implications elicit fierce debates when discussing their benefit–risk profile. These discussions usually come up, especially among GC ‘supporters’ and ‘opponents’,1 when trying to elaborate recommendations on how to use these drugs best in the treatment of rheumatic diseases such as rheumatoid arthritis (RA),2 polymyalgia rheumatica,3 giant cell arteritis,4 systemic lupus erythematodes,5 6 myositis7 and even systemic sclerosis.7 For example, very divergent opinions were learnt during work on the European League Against Rheumatism (EULAR) recommendations (2013 update) for the management of RA.2 As a result, only 73% (the lowest majority level of all recommendations) of the members approved the suggestion that GCs should only be used as bridging therapy for up to 6 months, ideally tapering them at earlier time points. Interestingly, when looking at the members voting against it, about half of them thought the statement was too weak, whereas the other half considered it to be too strong.2 Nevertheless, the level of agreement (strength of recommendation) was quite high (mean of 8.9) on final anonymous grading. It should also be noted that the group did not explicitly discuss the chronic use of GC in established RA.

Indeed, many patients and quite some physicians are still uncertain about the actual benefit:risk ratio of GCs.1 This uncertainty might prevent optimal treatment under conditions where GC treatment is known to be of added value. Fortunately, our view on the most optimal use of these drugs does slowly but constantly maturate. This primarily results from thorough analyses of accumulated data in order to update recommendations, but there are also new and often qualitatively better data coming in to enrich our knowledge. A …

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