Physician-Scientists to Review Ongoing Efforts to Reduce Steroid Use in Treating Rheumatic Diseases

For more than 70 years, steroids have been a mainstay in the treatment of rheumatic diseases. Since that time, research has demonstrated the toxicity associated with the long-term use of steroids, challenging clinicians to balance the effectiveness of steroids with the risks. An ACR Convergence 2024 session will feature a panel of physician-scientists who will discuss ongoing efforts to reduce, and perhaps eventually eliminate, the use of steroids in rheumatology practice.

Envisioning a Steroid-Free Future for the Treatment of Rheumatic Diseases will take place on Sunday, Nov. 17, from 10:30–11:30 a.m. ET in Room 146AB of the Walter E. Washington Convention Center. It will be available on demand within 48 hours for registered ACR Convergence 2024 participants.

John Stone, MD, MPH, Professor of Medicine at Harvard Medical School and the Edward A. Fox Chair of Medicine at Massachusetts General Hospital in Boston, will open the presentations with a discussion of the evolving role of steroids and the promise of emerging therapies in the management of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis.

“We’ve made consistent progress during this century with using less steroids, facilitated by the introduction of effective new therapies,” Dr. Stone said. “Avacopan, for example, was approved in 2021 and not only opened the possibility of using less steroid treatment but was also shown to actually decrease steroid toxicity.”

As new drugs to treat vasculitis enter the research pipeline, he said it will be important that drug trials are designed to demonstrate multiple benefits to patients, one of which should be reduction in steroid toxicity.

“There are some vasculitis trials coming up, in which the instruments to measure steroid toxicity have actually been employed, that include not only ANCA-associated vasculitis, but giant cell arteritis as well,” Dr. Stone said. “I don’t think we’re going to be abolishing steroids completely from the treatment of vasculitis for some years, but I think we are in a really good spot to continue the important conversation about using fewer steroids.”

Michelle Petri, MD, MPH, Professor of Medicine in the Division of Rheumatology and Director of the Lupus Center at the Johns Hopkins University School of Medicine and Johns Hopkins Hospital, will discuss the evolving approaches to reduce the role of steroids in the treatment of systemic lupus erythematosus (SLE).

“Cohort studies in SLE have highlighted that prednisone is directly or indirectly responsible for 80% of permanent organ damage in SLE,” Dr. Petri said. “While lupus activity plays a major role in skin damage and renal damage, for some organ damage, there is a clear dose response for prednisone’s association.”

Importantly, she said the most recent EULAR treatment guidelines for SLE, released in 2023, blaze new ground in mandating that prednisone maintenance should be 5 mg or less and recommending earlier intervention with immunosuppressive drugs and/or biologics.

“’The P in prednisone stands for poison’ is how I get the point across,” Dr. Petri said. “When we do need to use steroids, though, our data clearly point to the relative safety of intramuscular triamcinolone and/or IV methylprednisolone pulse.”

Beth Wallace, MD, MS, Associate Investigator at the VA Ann Arbor Center for Clinical Management Research and Assistant Professor in Internal Medicine at the University of Michigan, will discuss issues related to steroids in the treatment of rheumatoid arthritis (RA), including the challenge of tapering patients off of their use.

“There has really been a long tug-of-war in RA between using low-dose steroids as a long-term treatment, because they work, and avoiding steroids as much as we can, because they’re toxic. The paradigm is shifting toward thinking about not just how we control RA symptoms, which we can do with steroids, but how we control symptoms while also avoiding therapy-related toxicities,” Dr. Wallace said. “We certainly have reduced the number of people requiring long-term steroids, as the number of approved biologics has increased. However, we still have many people with RA who have been on steroids for years, a lot of whom have difficulty tapering off.”

When patients flare, clinicians currently have no alternative to help them in the short term other than steroids, she noted. So, the long-term goal must focus on recognizing RA early, getting patients on disease-modifying treatment quickly, and treating-to-target aggressively.

“That is something we’re going to have to continue to work toward from both the clinical side and the translational side,” Dr. Wallace said. “On the clinical side, we need to focus on treatment protocols that get people’s RA under control well enough that they don’t need steroids for flares. On the translational side, we need to develop treatment modalities that act quickly enough that we don’t need to rely on steroids until [those treatments] start working.”