Steroids and the Treatment of Autoimmune Conditions

On the second day of the 2023 Interdisciplinary Autoimmune Summit, Stephen B. Hanauer, MD, and Soumya Reddy, MD, presented their session, “Steroids as a Treatment for Autoimmune Conditions,” with the objective to review indications for steroids in immune-mediated inflammatory diseases (IMIDs) and the efficacy of steroid-sparing therapies.

Dr Stephen B. Hanauer, professor of medicine and medical director of the Digestive Health Center at Northwestern University’s Feinberg School of Medicine in Chicago, IL, discussed steroids for inflammatory bowel disease.

Steroids are part of the American College of Gastroenterology guidelines for moderate-severe ulcerative colitis (UC) or Crohn disease (CD). For UC, “[Steroids] have been recommended primariliy for the induction of remission,” he noted. “Our goal is to treat patients with steroids and get them off of it to limit the exposure over time.” For CD, “oral corticosteroids are effective and can be used for short-term use in alleviating signs and symptoms of moderate to severely active CD,” he commented.

Regarding steroid-sparing therapy, Dr Hanauer remarked, “Here, we are going to see more disappointment than enthusiasm because, as seen in clinical trails, we have much greater opportunity to have patients in a clinical remission than in a steroid-free remission.”

“Steroids are the rescue medication for all therapeutic failures,” he concluded.

Next, Dr Soumya Reddy, codirector of the Psoriasis and Psoriatic Arthritis Center at New York University’s Grossman School of Medicine in New York, NY, discussed corticosteroids used in rheumatology.

Dr Reddy started with the use of oral steroids in rheumatology. “Oral steroids solve some treatment challenges that no alternate therapies can and are, therefore, unlikely to be fully eliminated from the armamentarium,” she noted. “Despite increased DMARD [disease-modifying antirheumatic drugs] and biologic use over the past 2 decades, oral corticosteroid use in rheumatoid arthritis (RA) is largely unchanged.”

She touched on the controversy over use of low-dose steroids in RA. “Difficulty in tapering patients off steroids, fear of side effects with conventional and biologic diseasemodifying drugs, lack of early referral to rheumatologists, and lack of access to effective therapies can all contribute to chronic steroid use,” she indicated.

Dr Reddy moved on to discuss the use of oral steroids in different diseases such as juvenile idiopathic arthritis, psoriatic arthritis, systemic lupus erythematosus, vasculitis, giant cell arteritis, and polymyalgia rheumatica.

She then explored what has changed in the use of oral steroids in rheumatology:

• Increased awareness of long-term organ damage and mortality with chronic steroid use, even at low doses
• Expanded number of DMARD/biologic/directed therapies for many autoimmune diseases
• Recognition of difficulty in tapering or discontinuing steroids once initiated
• Increased awareness of the disproportionate effect of steroid adverse events in the pediatric population
• Quantification of steroid-related toxicities using the Glucocorticoid Toxicity Index
• Clinical trials demonstrating effectiveness of no-steroid or low-steroid treatment regimens

Dr Reddy concluded, “For now, steroids remain our friend as we will continue to use them as a useful tool in rheumatologist’s armamentarium for patients who do not respond adequately or have flares as a bridge to more targeted therapies. But they are constantly our enemy that we are fighting against as we continue this paradigm shift to minimize use of steroids both in dose and duration across all rheumatologic diseases.”

Reference
Hanauer SB, Reddy S. Steroids as a treatment for autoimmune conditions. Presented at: Interdisciplinary Autoimmune Summit; April 26–28, 2023; Virtual.