New guidelines on glucocorticoid-induced adrenal insufficiency: the end of short synacthen test in rheumatology?

This is the authors' abstract. We don't add key points for this paper.

Glucocorticoids (GCs) are widely employed in the management of inflammatory rheumatic diseases, particularly rheumatoid arthritis (RA), polymyalgia rheumatica, giant cell arthritis and systemic lupus erythematosus.1–3 The timing and approach for discontinuing long-term GC treatment remain a significant issue for rheumatologists in terms of disease control and also safety concerns related to the well-known risk of GC-induced adrenal insufficiency (GIAI).4–8 For instance, although the EULAR recommendations for RA management advocate for rapid GC tapering (aiming for discontinuation within about 3 months of initiation), recent data from the international TOCERRA and PANABA observational studies indicate that 40% of the 12 334 participants with RA continued oral GC therapy 1 year after initiating biological disease-modifying antirheumatic drugs, with a median time to GC discontinuation exceeding 2 years.2 9 In practice, Delteil et al reported two distinctive trajectories of GC discontinuation in patients with RA.10 One-quarter of them achieved GC discontinuation within the first year, while the remaining three-quarters had a more progressive GC tapering with a low-dose maintained at 2 years.10 These observations underscore the challenges associated with discontinuing GCs, which stem from inadequate disease control and safety concerns, including the risk of GIAI. Sagar et al reported that 43% of long-term GC-treated patients with rheumatic diseases exhibited evidence of possible GIAI.11 Comparable rates were observed in patients with RA treated with 5–7.5 mg/day of prednisolone for 3–6 months,12 13 and in those with polymyalgia rheumatica/giant cell arthritis.14 Furthermore, 13% of patients with systemic lupus erythematosus who had either discontinued prednisolone or were receiving <5 mg/day showed biological evidence of adrenal insufficiency.15 Finally, overt adrenal insufficiency was identified in 20% of patients with rheumatic and musculoskeletal diseases who experienced disease relapse during GC tapering.16