Loss of disease control (Case study 1, box 1)
Effective treatment of chronic inflammatory disorders is essential to prevent long term structural changes and loss of function, such as joint destruction and loss of mobility in rheumatoid arthritis or airways remodelling and chronic breathlessness in asthma. Glucocorticoids are highly effective in the treatment of inflammation but their utility is limited by their dose-related and continuous use adverse effects. ‘Steroid-sparing’ strategies can be employed to improve the benefit: harm ratio of glucocorticoids. General principles include combining systemic glucocorticoids with topical glucocorticoids (e.g. intraarticular for arthritis, high dose inhaled for asthma) and/or with conventional and biological disease-modifying drugs (e.g. methotrexate or adalizumab for rheumatoid arthritis, omalizumab for asthma). A holistic approach should also include reviewing the diagnosis and need for glucocorticoids. For example a patient with ‘asthma’ who seems poorly-responsive to high dose glucocorticoids may actually have COPD, where systemic glucocorticoids are not usually indicated.
As glucocorticoid treatment is weaned, reactivation of disease may be difficult to distinguish from end of treatment adverse effects or re-emergence of symptoms of unrelated conditions. For example, a patient with rheumatic disease who complain of aches and pains as glucocorticoids are withdrawn may be experiencing reactivation of their inflammatory disease, ‘pseudorheumatism’ of glucocorticoid withdrawal, or renewed awareness of underlying osteoarthritis. These will affect the treatment taper in different ways. A disease flare may require an increase in glucocorticoid dose, although a relatively modest increase e.g. to the last effective dose in polymyalgia rheumatica [25], may be enough. Symptoms of glucocorticoid withdrawal syndrome or renewed awareness of underlying conditions can be managed with alternative therapies, such as non-steroidal anti-inflammatories for rheumatic symptoms. Slowing the taper may also allow glucocorticoid withdrawal symptoms to resolve.
Patient perception of glucocorticoids may affect their willingness to take treatment, with non-adherence leading to loss of disease control (Box 1). Anecdotally many patients starting glucocorticoid treatment express fears of weight gain, skin changes and ‘becoming addicted’ with one patient being particularly concerned because a relative had died from glucocorticoid-related adverse effects. These anecdotes are born out by studies of patient perceptions of glucocorticoid therapy, which found that patients voiced concerns about adverse effects [26] and, given a ‘risk-free choice’, preferred withdrawal of glucocorticoids over other agents [27]. It is essential that the benefits and risks of treatments and patient concerns are fully discussed before starting treatment and that the decision to undertake glucocorticoid treatment is made jointly by patient and practitioner.