Glucocorticoids in paediatric rheumatology

Glucocorticoid (GC) drugs are the most potent anti-inflammatory agents available for the treatment of paediatric rheumatic diseases. These medications are used for the management of extra-articular features of systemic juvenile idiopathic arthritis and are the mainstay of therapy in children with juvenile systemic lupus erythematosus, juvenile dermatomyositis, and systemic vasculitis. The general objective of GC therapy is to limit the maximal dose and the exposure to the highest doses to what is needed to achieve disease control and, then, to gradually taper the dose until the minimum level sufficient to maintain disease quiescence over time is reached. High-dose intravenous 'pulse' methylprednisolone administration is sometimes chosen to treat the most severe or acute manifestations of systemic inflammatory diseases. The rationale that underlies this treatment modality is to achieve an immediate, profound anti-inflammatory effect and to lessen toxicity associated with long-term continuous therapy in moderate to high daily doses. Intra-articular corticosteroid (IAC) injection is a safe and rapidly effective treatment for synovitis in children with JIA. Triamcinolone hexacetonide is the optimal corticosteroid preparation. Local injection therapy is used most frequently to treat oligoarthritis, but the strategy of performing multiple IAC injections to induce disease remission, while simultaneously initiating therapy with second-line or biologic agents, has been proposed also for children with polyarticular JIA. Administration of GCs is associated with potentially deleterious adverse effects, some of which can be irreversible. This highlights the need of a judicious use of these medications and a careful monitoring of their toxicity.