Rheumatology and long term steroids

[bedrock]

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I did a month of rheumatology in residency and I don’t remember this being a thing.

I have noticed that two local rheumatologists in different cities near me that right after they diagnose someone with autoimmune disease, even things without a firm diagnosis (like
undifferentiated connective tissue issues)
They will start plaquenil or methotrexate, which is fine, but they also put patients on oral steroids for 6-8 weeks!! At 10-20mg of prednisone per day.

Is that now the standard of care/normal to start every new autoimmune patient on oral steroids for a couple months?

I’m not excited about this from a bone health and endocrine standpoint.

 

[Agast]

Hm it seems more like a last resort in my area. For one, it makes it harder to monitor response to treatment because it will interfere with inflammatory markers. Maybe those rheumatologists got tired of submitting prior auth requests for the better drugs.

 

[Ferrismonk]

I see people on long term steroids from Rheum all the time, but I definitely think it's not-first line therapy. I'm pretty sure it's a combination of old-docs and what Agast says being correct.

 

[callmeanesthesia]

Where I am I’ve only seen that for polymyalgia rheumatica, for which I understand that’s standard of care.

 

[SSdoc33]

no, its because the steroid make them immediately feel better and it gives time for the DMARDs to work.

makes the patients feel like their docs are miracle workers. even though it is not good medical practice, and not SOC. i see it from time to time, but not routinely

 

[bedrock]

no, its because the steroid make them immediately feel better and it gives time for the DMARDs to work.

makes the patients feel like their docs are miracle workers. even though it is not good medical practice, and not SOC. i see it from time to time, but not routinely

That is helpful. Thanks

 

[lobelsteve]

If more than 4 weeks of oral steroid above 5mg, should have prophylactic bisphosphonates. Or Prolia.

 

[dozitgetchahi]

I did a month of rheumatology in residency and I don’t remember this being a thing.

I have noticed that two local rheumatologists in different cities near me that right after they diagnose someone with autoimmune disease, even things without a firm diagnosis (like
undifferentiated connective tissue issues)
They will start plaquenil or methotrexate, which is fine, but they also put patients on oral steroids for 6-8 weeks!! At 10-20mg of prednisone per day.

Is that now the standard of care/normal to start every new autoimmune patient on oral steroids for a couple months?

I’m not excited about this from a bone health and endocrine standpoint.

This is a combination of old school rheumatology thinking, cluelessness and (occasionally) necessary evil. It also depends on the diagnosis.

The old guard within rheumatology was much more free about writing NSAIDs, steroids, opioids, etc. This is partially a relic of a time where rheumatology didn’t have a lot of other great treatment options. The “new wave” within rheum is to use steroids and NSAIDs sparingly, and opioids etc never (I write no controlled substances whatsoever). For inflammatory polyarthritis, I try to get away without writing steroids if I can, and if I must it’s 5-10mg of prednisone a day as needed, and we’re stopping it as soon as the DMARDs are working.

Occasionally you find a patient who is miserable with inflammatory arthritis, and whom a number of DMARDs have struck out/not worked/not been tolerated, and in those situations yes we do keep the steroids going for a time as a necessary evil to keep these people functioning until we get to a bDMARD etc that works. This happens relatively rarely nowadays, as we have better and better medications.

In general, I take no joy whatsoever in writing a script for steroids. I’m aware of the side effects and as the years go on, the amount of evidence that argues against using even modest doses of steroids for various purposes only seems to increase. They’re a “stopgap” in most situations that we (in modern rheumatology) use at most for brief periods of time while we wait for other medications to start working.

Another type of “necessary evil” is when people have a hardcore diagnosis that calls for fast intense immunosuppression. A new ANCA vasculitis diagnosis, severe lupus, etc etc often will involve a fairly long high dose steroid taper as other treatments take effect (although this is changing in some circumstances as newer treatments emerge).

(As a rheumatologist, I agree that a lot of my colleagues seem to overuse steroids. I work near two “old guard” rheums and I inherit a lot of their patients. I do a lot of tapering of steroids and other things with these patients. I’ve also had pain doctors overstep boundaries with managing steroids in the past, in one case stopping my steroids in a rather severe lupus nephritis case that we had just barely gotten under control with Cellcept and other things. That wasn’t cool, at all.)

 

[Ducttape]

The rheums around me almost never use steroids.

Yes there was an old guard that used it all the time. But they trained and worked in an era where steroids were really the mainstay of treatment.

 

[Gauss]

For inflammatory polyarthritis, I try to get away without writing steroids if I can, and if I must it’s 5-10mg of prednisone a day as needed, and we’re stopping it as soon as the DMARDs are working.

and the insurer covers it affordably... infusion and injectable OOP amounts are wild and unpredictable

 

[bedrock]

This is a combination of old school rheumatology thinking, cluelessness and (occasionally) necessary evil. It also depends on the diagnosis.

The old guard within rheumatology was much more free about writing NSAIDs, steroids, opioids, etc. This is partially a relic of a time where rheumatology didn’t have a lot of other great treatment options. The “new wave” within rheum is to use steroids and NSAIDs sparingly, and opioids etc never (I write no controlled substances whatsoever). For inflammatory polyarthritis, I try to get away without writing steroids if I can, and if I must it’s 5-10mg of prednisone a day as needed, and we’re stopping it as soon as the DMARDs are working.

Occasionally you find a patient who is miserable with inflammatory arthritis, and whom a number of DMARDs have struck out/not worked/not been tolerated, and in those situations yes we do keep the steroids going for a time as a necessary evil to keep these people functioning until we get to a bDMARD etc that works. This happens relatively rarely nowadays, as we have better and better medications.

Another type of “necessary evil” is when people have a hardcore diagnosis that calls for fast intense immunosuppression. A new ANCA vasculitis diagnosis, severe lupus, etc etc often will involve a fairly long high dose steroid taper as other treatments take effect (although this is changing in some circumstances as newer treatments emerge).

(As a rheumatologist, I agree that a lot of my colleagues seem to overuse steroids. I work near two “old guard” rheums and I inherit a lot of their patients. I do a lot of tapering of steroids and other things with these patients. I’ve also had pain doctors overstep boundaries with managing steroids in the past, in one case stopping my steroids in a rather severe lupus nephritis case that we had just barely gotten under control with Cellcept and other things. That wasn’t cool, at all.)

Thank you very much for your insight

 

[dozitgetchahi]

and the insurer covers it affordably... infusion and injectable OOP amounts are wild and unpredictable

Yes, to some extent.

But:
- between insurance coverage and drug company assistance, you can get practically everyone covered one way or another these days. I can count on one hand the number of patients I’ve had who truly couldn’t get good coverage for a biologic, and were looking at having to pay big sums of money OOP. Usually in these situations, it’s as simple as switching to a different medication and/or having your staff maneuver a bit.

- cDMARDs still work well for a lot of folks. Sometimes the answer is just getting someone set up on a different combo of those.

 

[Ducttape]

one patient told me it would cost $20k yearly for Orencia, but $500 a year for Humira, if i remember correctly...

of course, she unabashedly stated that Orencia worked so much better (i believe she had 1 round of treatment with it) and it was all her rheumatologists fault. and i am fairly certain that she told the rheumatologist it was my fault......