Challenges of glucocorticoid therapy
Glucocorticoid therapy has the potential for considerable benefit through control of life-threatening and/or disabling disease, but at the cost of considerable harms through dose-related and continuous use adverse reactions. The goal of glucocorticoid therapy is therefore to obtain the maximum possible therapeutic benefit at the lowest possible dosage, both average and cumulative, to minimise adverse effects. In practice, this is achieved by starting glucocorticoid treatment at a moderate to high dose (e.g. 40 mg prednisolone for an asthma exacerbation, 1000 mg methyl prednisolone for graft rejection reactions or relapse in multiple sclerosis) to gain disease control, then withdrawing glucocorticoid treatment to as low dose as can be achieved while still maintaining disease control. Glucocorticoid withdrawal is greatly complicated by the emergence of symptoms, which may be a manifestation of disease reactivation, an end-of-use adverse reaction caused by drug withdrawal (adrenal insufficiency, glucocorticoid withdrawal syndrome) or psychological dependence (figure 3). Distinguishing between these and supporting patients in successful withdrawal of glucocorticoids can be a considerable challenge.