“There has to be an acceptance that steroids are now an undesirable part of treating most rheumatic diseases, and our prescribing behavior must change.”
Michelle Petri MD, MPH is a leading international authority on systemic lupus erythematosus (SLE) and is the Director of the Hopkins Lupus Cohort, and co-Director of the Hopkins Lupus Pregnancy Center. The Hopkins Lupus Cohort is perhaps the largest longitudinal cohort study of morbidity and mortality in lupus patients in the world.
Lupus is a disease that tends to affect young women, so the impact of glucocorticoid toxicity from long-term steroid use in terms of weight gain, skin toxicity (acne, hirsutism, stretch marks), neuropsychiatric effects, hypertension, and osteoporosis are particularly problematic from an early age in life.
She found her calling to help lupus patients during her time as a student at Harvard Medical School. “Seeing young women dying from autoimmune diseases such as lupus is terrible, and I wanted to make a difference. I don’t think I’m alone in this, over half of all rheumatologists are female.”
She describes lupus as “a terrible autoimmune disease usually starting in young adulthood that increases mortality, and in particular patients causes a slew of chronic organ damage - 15 years after the diagnosis of lupus 80% of the permanent organ damage is actually due to steroids. So in lupus, in particular, there's a huge impetus to reduce and stop reliance on prednisone as one of the mainstays of treatment.”
Dr Petri explains the use of glucocorticoids for lupus is almost universal because they work fast, and are cheap. The problem she says is “the terrible price the patients then pay later.”
“It now must be accepted it's wrong to rely on maintenance steroids to treat lupus. There are a lot of new immunosuppressive drugs and we've gotten very smart about which ones to use for which organs, and in the United States there's relative ease to get biologics for people with lupus even though they can be extremely expensive.”
As a clinical researcher, she opines that it is essential that we measure steroid toxicity in all of our autoimmune disease clinical trials using a standard clinical outcome assessment instrument such as the Glucocorticoid Toxicity Index.
“Using the same measurement instrument would allow comparison between trials and allow the FDA to have a very objective measure to use to approve a therapy as steroid-sparing. This would also help insurance companies come on board because steroid use leading to chronic damage leads to a huge increase in care costs. Insurance companies don't always seem to care about the patient the way a physician does - they care about reducing costs.”
“So if reducing steroids reduces costs, I think that insurance companies will come on board when a new therapy is approved that can reduce steroid use.”
As a practicing rheumatologist, she also sees the need to change prescriber behavior. “Often the patient will ask for the prednisone and all too often the physician will write the prescription and there's no discussion that this is the wrong long-term approach.”
“I believe it's essential, that there be some stop sign in the electronic patient record that would force that conversation. Having a version of the Glucocorticoid Toxicity Index that could be built into the EPR and generate a big red pop-up that takes up the whole screen and urges providers to record data and to think differently about the prescription would provide the wake-up call that is so often needed.”
She stresses that while there is a general understanding that glucocorticoids have toxic side effects, clinicians are busy trying to see so many critically ill patients in a short period of time that there are too many things tugging on that physician for the side effects of a prednisone prescription to be top-of-mind.
“Physicians also know the steroids will work, and that it's easy to write a prescription because no insurance company ever challenges it and the patient can collect it the same day. This behavior of following the path of least resistance can have terrible consequences and I think that physicians need a little bit of a prompt and a wake-up call. Just because it's easy doesn't mean it's acceptable.”
Dr Petri’s biggest hope is that her research helps change prescribing behavior as her team has shown that it doesn't take much maintenance prednisone to increase later damage in lupus.
“We've shown that just six milligrams [of prednisone] are enough to increase permanent later organ damage. And even more alarming is if the maintenance dose gets to be 10 milligrams there's over twofold increase in myocardial infarction and stroke - which are of course major causes of disability and death.”
“There has to be an acceptance that steroids are now an undesirable part of treating most rheumatic diseases, and our prescribing behavior must change.”
Michelle Petri, MD MPH is a Professor of Medicine at the Johns Hopkins University School of Medicine. She attended medical school at Harvard University and fulfilled her internal medicine residency at the Massachusetts General Hospital. In addition, she completed two fellowship programs at the University of California, San Francisco in allergy and immunology and rheumatology. Dr. Petri is the Director of the Hopkins Lupus Cohort, a longitudinal study of morbidity and mortality in systemic lupus erythematosus, and Co-Director of the Hopkins Lupus Pregnancy Center.