“We have a saying in China, ‘to turn pale at the mention of a tiger’, and this describes the fear many patients show when told they need to be prescribed steroids.”
Wen Zhang, MD PhD is a Professor in the Rheumatology Department at Peking Union Medical College Hospital (PUMCH), Beijing, China – known as the cradle of modern Chinese medicine. Since 2011, she has focused her research on IgG4-related disease (IgG4-RD), but her expertise also encompasses Sjögren’s syndrome, systemic lupus erythematosus, systemic vasculitis, antiphospholipid syndrome, and the SAPHO syndrome.
As a young physician, she was inspired to study under the mentorship of Professor Naizheng Zhang, the founder of Chinese rheumatology, who founded the rheumatic disease clinic in PUMCH (the first rheumatology center in China) and participated in compiling the rheumatology portion of the National Plan for the Development of Science.
Dr Zhang was drawn to researching IgG4-RD because it allows her to combine two passions, the ability to research a recently recognized disease - helping a large number of patients in the process; and use the expertise and knowledge of the immune system she gained during a postdoc with Professor Peter Lipsky at the US National Institutes of Health.
“IgG4-related disease is a systemic disease that can affect nearly any organ and is characterized by IgG4+ plasma cells. Patients can have very different clinical characteristics and manifestations which can complicate diagnosis.”
Dr Zhang explains that while biologic treatments such as rituximab can yield good response rates, recurrences are common, leaving glucocorticoids as a first-line treatment.
“IgG4-related disease is highly sensitive and responsive to treatment by steroids, and while we also combine other immunosuppressive medicines, steroids are a mainstay of treatment.
This treatment really is a double-edged sword. While steroids have a dramatic effect on inflammatory diseases such as IgG4-related disease, there is a long list of toxicities associated with their use. These include osteoporosis, diabetes, opportunistic infection and bone necrosis – and whenever my patients suffer any of these I really feel sorry for them and wish we had alternative treatments we could prescribe.”
While she does carefully taper patients to as low a dose as possible, Dr Zhang recognizes many patients do become reliant on steroids to stop the disease from relapsing. The double-edged nature of steroids means that patients in China are often terrified of being prescribed them.
“We have a saying in China, ‘to turn pale at the mention of a tiger’, and this describes the fear many patients show when told they need to be prescribed steroids. They want to get better and avoid relapses, but they really don’t want to take steroids.
Many patients will ask me: ‘Do I have to take steroids? Are there any other drugs we could try instead?’ Having to tell them there are no realistic alternatives is really sad.
We really need more steroid-sparing medicines that will help patients with IgG4-related disease.”
Dr Zhang heralds the development of the Steritas Glucocorticoid Toxicity Index (GTI) as ushering in a new age of evidence-based assessment of steroid-toxicity that will help deliver new therapies, better treatment protocols, and better patient outcomes.
“The GTI is the first and only quantitative measure of steroid-toxicity. It enables doctors to monitor and precisely evaluate the impact of steroids, removing subjectivity from the assessment. It allows us to quantify the scale of adverse reactions a patient has to steroids and also helps us taper steroid treatments and look after our patients more effectively.
Steroids are a huge burden on patients both physically and psychologically. Whenever we prescribe them we need to describe the side effects and what we can do to prevent them - often that involves giving a lot of additional drugs to treat or prevent the toxicities.”
Many of Dr Zhang’s IgG4-related disease patients are middle-aged or older and therefore very susceptible to steroid-toxicities such as diabetes and osteoporosis. Because IgG4-RD patients tend to respond very well to steroids, she recommends her colleagues prescribe a medium dose to most patients to help keep the impact of steroid-toxicity to a minimum while treating the patient effectively.
“Steroids are widely used to treat rheumatic diseases, and are sometimes overused. We regularly caution colleagues to tightly control the dosage and take efforts to minimize the side effects of steroid treatment as much as possible.
In recent years, we have seen more and more steroid-sparing therapies being developed which brings us more opportunities to reduce steroid doses and even discontinue them altogether. The GTI will help make more steroid-sparing therapies available to us, and give us even more options to reduce steroid-toxicity.”
Dr Wen Zhang is a Professor in the Rheumatology Department at Peking Union Medical College Hospital (PUMCH), Beijing, China and has been working as a physician for 31 years.
Dr Zhang has focused on IgG4-related disease since 2011. Her expertise encompasses IgG4-RD, Sjogren’s syndrome, systemic lupus erythematosus, systemic vasculitis, antiphospholipid syndrome, SAPHO syndrome. She also participated in international consensus guidelines on the management of IgG4 related-disease, and the 2019 ACR/EULAR classification criteria for IgG4-RD.
She received her PhD degree in Rheumatology, Department of Rheumatology, Peking Union Medical College, Beijing, China, and her M.D. degree in Medicine, West China Medical University, China