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Views on glucocorticoid therapy in rheumatology: the age of convergence

Abstract

After decades of sometimes fierce debate about the advantages and disadvantages of glucocorticoids, an age of convergence has been reached. Current recommendations for the management of diseases such as rheumatoid arthritis (RA), polymyalgia rheumatica and large vessel vasculitis reflect the current consensus that as much glucocorticoid as necessary, but as little as possible, should be used. Over the past few years, a range of glucocorticoid-sparing strategies have been developed, as have tools to improve the management of this therapy. A comprehensive view of glucocorticoid-induced osteoporosis has also emerged that recognizes that bone fragility is not solely determined by the dose and duration of glucocorticoid treatment. Nevertheless, open questions remain around whether long-term use of very low doses of glucocorticoids is a realistic option for patients with RA and whether the search for innovative glucocorticoids or glucocorticoid receptor ligands with improved benefit-to-risk ratios will ultimately be successful.

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Fig. 1: Important developments in glucocorticoid use in rheumatology.
Fig. 2: Factors that influence osteoporosis-related bone fragility in rheumatic diseases.

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Correspondence to Frank Buttgereit.

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Competing interests

F.B. declares that he has received consultancy fees, honoraria, travel expenses and grant support from Horizon Pharma, Mundipharma, Pfizer and Roche. The work of F.B. in the ongoing Rh-GIOP study (Glucocorticoid-induced osteoporosis in patients with chronic inflammatory rheumatic diseases or psoriasis; NCT02719314) is supported by joint funding from Amgen, BMS, Celgene, Generic Assays, GSK, Hexal, Horizon, Lilly, Medac, Mundipharma, Novartis, Pfizer, Roche and Sanofi.

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Nature Reviews Rheumatology thanks P. Verschueren, E. Matteson and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Amaurosis fugax

A painless temporary loss of vision in one or both eyes.

Bridging therapy

The use of glucocorticoids in patients who initiate conventional synthetic DMARD treatment or need to be switched to another such drug to bridge the period until treatment with the new agent has become effective.

Chronobiology

A branch of biology concerned with cyclical physiological phenomena.

Cushingoid habitus

A physique that resembles that observed in individuals with Cushing disease (a condition in which the pituitary gland releases too much adrenocorticotropic hormone), but is caused by treatment with synthetic glucocorticoids.

Pulse therapy

Treatment with >250 mg prednisone equivalent daily for 1 or a few days.

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Buttgereit, F. Views on glucocorticoid therapy in rheumatology: the age of convergence. Nat Rev Rheumatol 16, 239–246 (2020). https://doi.org/10.1038/s41584-020-0370-z

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