IgG4-Related Disease: Navigating Diagnosis and the Expanding B-Cell-Targeted Treatment Landscape - Episode 9
Glucocorticoid Toxicity in IgG4-RD: Why Shorter Steroid Courses Matter
In older patients with diabetes, cardiovascular disease, and osteoporosis, glucocorticoid harms are magnified. The panel explains why minimizing steroid exposure is central to treating a relapsing disease.
This episode, "Glucocorticoid Toxicity in IgG4-RD: Why Shorter Steroid Courses Matter," features the panel weighing the clear efficacy of glucocorticoids against their cumulative toxicity.
Dr. Culver asks Dr. Della Torre about his main concerns regarding glucocorticoid toxicity. He explains that rheumatologists and immunologists learned these harms largely from other immune-mediated diseases, such as lupus and rheumatoid arthritis. Clinicians are familiar with the consequences of prolonged use. These include cataracts, atherosclerosis, cardiovascular disease, obesity, and diabetes.
In IgG4-related disease, Dr. Della Torre argues, these risks are amplified in a frail population. Patients are, on average, older than 60 years. Many already have diabetes or cardiovascular and metabolic disorders, which glucocorticoids may accelerate. He adds that toxicity also varies worldwide because populations and ethnicities metabolize glucocorticoids differently.
He believes the shorter the course of steroids, the better, provided equally effective alternatives exist. Glucocorticoids are highly effective, he acknowledges. He is pleased that Dr. Katz uses them as clinicians do in Europe. Both reserve short courses of medium- to high-dose therapy for specific manifestations. When alternatives are available, he would choose a more pathogenesis-targeted treatment with fewer side effects.
Dr. Della Torre emphasizes that the disease is relapsing. He cannot recall a single patient in his cohort who did not ultimately relapse, even after 7 or 10 years. Given that near-certainty, he cannot keep patients on glucocorticoids for too long. Clinicians know the cumulative toxicity of these drugs too well.
Dr. Culver agrees that glucocorticoids work quickly but carry short- and long-term systemic toxicity. She notes exceptions. Some patients have adrenal insufficiency from prior glucocorticoid exposure. Others have pituitary involvement that affects adrenal function and may need long-term low-dose replacement. Some patients started on steroids by another physician are reluctant to stop. In those cases, she tapers very slowly to avoid withdrawal effects. She closes by agreeing that getting patients off steroids remains the goal.
Up next, in "Predicting Relapse in IgG4-RD: Risk Factors and Ongoing Surveillance," Dr. Katz walks through the markers that signal higher relapse risk and the limits of prediction for individual patients.
