Glucocorticoid treatment in patients with inflammatory rheumatic diseases: current practice and open questions

Glucocorticoids remain a cornerstone in treating inflammatory rheumatic musculoskeletal diseases due to their rapid, potent anti-inflammatory effects. However, their long-term use carries well known risks, such as their cumulative toxicity, leading to international consensus that glucocorticoids should be given at the lowest effective dose and for the shortest duration, and discontinued whenever clinically feasible. In rheumatoid arthritis, systemic lupus erythematosus, and polymyalgia rheumatica, modern guidelines recommend short-term glucocorticoid use as bridging therapy at the lowest effective dose, often feasible through concomitant disease-modifying antirheumatic drugs or immunomodulatory or suppressive agents. However, registry and cohort data show chronic glucocorticoid therapy (>6 months) remains common. Contributing factors include difficult-to-treat disease, flares during tapering, limited access to glucocorticoid-sparing therapies, reluctance by physicians or patients to discontinue, barriers to implementing guideline-based care, and other barriers. However, new evidence indicates that, when clinically necessary, longer-term glucocorticoid therapy with very low doses (