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glucocorticoids are withdrawn may be experiencing reactivation of their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.