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.