Do the treatment with glucocorticoids and/or the disease itself drive the impairment in glucose metabolism in patients with rheumatoid arthritis?

Opinions on the value of glucocorticoids (GCs) have fluctuated between euphoric acceptance and outright rejection. This ambivalence in opinions arose because of their important clinical effects, on one hand, and their potential risks, on the other hand.1 2 It seems, however, that these important drugs have now found their correct place in rheumatology (and other special areas in medicine). The current view on these drugs is that they are indispensable; however, they should be administered as much as necessary but as little as possible. Without any doubt, GCs at higher dosages are needed to terminate flares and/or to reduce the activity of rheumatic diseases. However, this ‘emergency’ usage represents only one option for successfully administering these drugs since many patients are more or less continuously treated with ‘maintenance treatment’. For example, when looking at rheumatoid arthritis (RA), it is obvious that, very often, lower dosages of GCs are given in combination with conventional or biological disease-modifying anti-rheumatic drugs (DMARDs) (and, of course, other drugs such as non-steroidal anti-inflammatory drugs or analgesics). This therapeutic approach has the following rationale: a sensible combination of drugs with different modes of action ideally results in additive or even synergistic effects, while potential adverse effects remain at a level associated with the dose of each component. For GC treatment, this means that the more effective the treatment is with DMARDs, the lower can be the GC dosages. Consequently, less pronounced adverse effects are induced by these drugs (figure 1). Figure 1 Drug combination in rheumatoid arthritis treatment. A sensible combination of drugs with different modes of action ideally results in additive or even synergistic effects, while potential adverse effects remain at a level associated with the dose of each component. Given the widespread and successful usage of biological DMARDs, what does this mean in terms …