As rheumatologists, we have a love-hate relationship with the corticosteroid prednisone, a feeling many of our patients share. It’s our most effective medication to quickly shut down an overactive immune system. When we have a patient with life- or organ-threatening autoimmune disease—severe lupus affecting the kidneys or vasculitis causing hemorrhage in the lungs, for example—large doses of prednisone are the most immediate treatment and are considered the standard of care. When a patient has a flare of rheumatoid arthritis, a moderate dose of prednisone can make a remarkable difference within a few days. Among patients with polymyalgia rheumatica, even tiny daily doses of prednisone can make patients with severe muscle pain and stiffness feel normal for years.
Explore this issueDecember 2018
But prednisone can also cause significant harm. Taking high doses can raise blood pressure and blood sugar, significantly increasing the risks for cardiovascular disease and diabetes. Long-term use can reduce bone strength, increasing the risk for hip, spine and other fractures due to osteoporosis. In patients with lupus, high doses of prednisone often lead to avascular necrosis (dead bone in the hips and other large joints), a condition that can be remedied only by total joint replacements. And because prednisone suppresses the body’s immune system, taking it can also result in a substantial increase in the risk of mild to serious infections.
A medication that offers the benefits of prednisone without its side effects would be a tremendous breakthrough in rheumatology. This is essentially what every tested immunosuppressant drug is trying to be—thus far unsuccessfully.