Glucocorticoid treatment in patients with inflammatory rheumatic diseases: current practice and open questions

Glucocorticoids remain a cornerstone in treating inflammatory rheumatic musculoskeletal diseases due to their rapid, potent anti-inflammatory effects. However, their long-term use carries well known risks, such as their cumulative toxicity, leading to international consensus that glucocorticoids should be given at the lowest effective dose and for the shortest duration, and discontinued whenever clinically feasible. In rheumatoid arthritis, systemic lupus erythematosus, and polymyalgia rheumatica, modern guidelines recommend short-term glucocorticoid use as bridging therapy at the lowest effective dose, often feasible through concomitant disease-modifying antirheumatic drugs or immunomodulatory or suppressive agents. However, registry and cohort data show chronic glucocorticoid therapy (>6 months) remains common. Contributing factors include difficult-to-treat disease, flares during tapering, limited access to glucocorticoid-sparing therapies, reluctance by physicians or patients to discontinue, barriers to implementing guideline-based care, and other barriers. However, new evidence indicates that, when clinically necessary, longer-term glucocorticoid therapy with very low doses (<5 mg/day), under careful monitoring, might offer an acceptable safety profile, although cumulative risks persist. In patients with unmet therapeutic needs, rational strategies combining disease-modifying antirheumatic drugs with very low-dose glucocorticoids might improve outcomes, reduce the frequency and severity of disease flares in diseases amenable to glucocorticoid therapy while maintaining toxicity within acceptable limits, and help to overcome the ceiling effect in rheumatoid arthritis. This Review summarises current recommendations, highlights the gap between guidelines and clinical practice, and discusses optimal approaches for glucocorticoid reduction, discontinuation, and potential safe long-term low-dose use, focusing on rheumatoid arthritis, systemic lupus erythematosus, and polymyalgia rheumatica.