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Glucocorticoid Sparing in non-RA Rheumatic Diseases
June 12 2015 8:00 AM ET — via RheumReports
The adverse effects associated with long-term glucocorticoid use are well known and yet when faced with conditions such as GCA and SLE, they remain the first-line treatment in order to get the disease process under control. This session focused on two case studies: one on GCA and the other on SLE where high doses of prednisone where initiated and subsequently tapered only to result in relapse. In both cases, the addition of immunosuppressant treatment was delayed until a second relapse occurred, based on a further attempt at tapering.
The guidelines regarding GCA are old (1990) and current thinking is to add immunosuppressant treatment at the initiation of prednisone to allow for a better response when tapering. Methotrexate is the only agent with RCT evidence for this purpose yet the data shows only a modest effect. Greater effects have been observed with the use of leflunomide at 10-20mg daily, but not in RCTs. When diarrhea or other adverse effects make this dose difficult, 10mg every other day may be helpful. IL-6 inhibition has also shown promise in refractory patients with CT improvement, and the IL-6 inhibitor gevokizumab is under investigation. Anti-TNF therapy has shown disappointing results.
In SLE, studies report various degrees of success in tapering glucocorticoids. Dr. Matthias Schneider's opinion was that glucocorticoids should only be used when there is a clear target for treatment, and should be discontinued once that target is reached or if the glucocorticoid is ineffective. Of note, many of the adverse effects of glucocorticoids can also be manifestations of SLE and this must also be considered.
Dr. Scheider added that fatigue and arthralgias are not an indication for glucocorticoid therapy and advised avoiding their use if the treatment target is uncertain. All patients should be on a baseline of antimalarial treatment from the onset of diagnosis, and should not be discontinued. In the event that tapering to a level of 5mg of prednisone a day is not possible, a second immunosuppressant agent is needed.
More research on tapering strategies is needed for both of these conditions since expert opinion is driving most of the strategies used and a consistent approach is lacking.
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About the Author
Carolyn Whiskin
Carolyn Whiskin, BSc. Phm is currently the director of pharmacy programs for the Charlton Centre for Specialized Treatments in Hamilton, Ontario. She also practices pharmacy at Brant Arts Dispensary in Burlington, Ontario and is the pharmacist representative to the Ontario Rheumatology Association’s Model of Care committee.
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