More than 50 million people around the globe are prescribed glucocorticoids to help manage/treat their inflammatory diseases. The latest guidelines developed by the American College of Rheumatology suggest treatment with glucocorticoids should be limited to the lowest effective dose for the shortest duration possible as “the toxicity associated with glucocorticoids was judged to outweigh potential benefits”.

The authors acknowledge that short-term glucocorticoid use is frequently necessary to alleviate symptoms and they highlight that taking glucocorticoids at a dose of greater than 2.5mg for longer than 3 months can put patients at risk for steroid toxicities such as glucocorticoid-induced osteoporosis. 

The updated guidelines developed by the American College of Rheumatology for the pharmacologic treatment of rheumatoid arthritis [1]  provide general guidance for common clinical

scenarios.

What are the new ACR guidelines?

The new ACR guidelines for the treatment of rheumatoid arthritis are intended to serve as a tool to support clinician and patient decision-making. The authors state that recommendations are not prescriptive, and individual treatment decisions should be made through a shared decision-making process based on patients’ values, goals, preferences, and comorbidities. [1] 

Most of the recommendations in the updated 2021 guidelines are additions to or clarifications of the 2015 recommendations. The most recent update revisits disease-modifying antirheumatic drugs, which are preferred in patients with low disease activity, and the use of glucocorticoids in patients with moderate-to-high disease activity. The new guidelines also include new recommendations on the administration of methotrexate and the treatment of patient populations not previously addressed.

There were two key changes from the previous guidelines:

1. While the prescription of methotrexate is generally a preferred option, this update recommends an initial trial of either hydroxychloroquine or sulfasalazine for those with low disease activity to test efficacy.
2. The panel recommends that tapering glucocorticoids be conducted carefully, and patients should be closely evaluated during any taper. If a flare occurs, they recommend the prior regimen be reinstated promptly.
3. The update includes several recommendations against the use of glucocorticoid therapy, due to the increasing evidence of the negative impact of glucocorticoids on long-term patient outcomes, including risk for infection, osteoporosis, and cardiovascular disease, in rheumatoid arthritis and other rheumatic diseases. They also cite how difficult glucocorticoid tapering can be.
   
   

New advice published by the ACR for patients

The development of the new guidelines has led the ACR to update its patient-facing content in particular highlighting that patients taking glucocorticoid medications are at increased risk of developing glucocorticoid-induced osteoporosis that can lead to bone fractures. [3]

While there are other risk factors such as low levels of estrogen, anorexia nervosa, smoking, alcohol abuse, low calcium and vitamin D, the negative impact of steroids is impossible to overlook. Patients taking glucocorticoids are at a higher risk of bone fractures because steroids can lower their bone densities. Even GC-treated patients with high bone densities have a greater fracture risk than steroid-naive patients with the same bone density.[3]

The American College of Rheumatology recommends that people taking glucocorticoid medications consume at least 1,200 mg of calcium and 800 to 1,000 International Units (IU) of vitamin D daily. In some cases, drug treatment is also required, depending on individual risk factors, dose, and duration of glucocorticoid medication.

How the Steritas Glucocorticoid Toxicity index (GTI) can support adoption of the new guidelines

Steroid-toxicity is a vexing problem for many rhematologists, and its measurement has proven a particularly difficult challenge for the practicing clinician. The Steritas GTI provides a fast, accurate, and easy to implement, weighted outcome score of steroid-toxicity and is being licensed in more than 45 studies, including 12 phase 3 clinical trials. The high benefit of the GTI has already been proven in use in numerous clinical studies and was found to be the most important secondary endpoint in the approval of avacopan.

The GTI is also being used by a number of clinicians to guide glucocorticoid treatment and tapering, and is useful to the general clinician at the point of care.