Glucocorticoids are a double-edged sword: Although they often offer near-instantaneous relief for suspected rheumatologic disorders, their long-term use is harmful and unsustainable. And yet steroid overprescription remains an ongoing issue, especially in primary care.

Poor communication between primary care physicians and rheumatologists remains a concern, whereas delays in accessing specialist care can leave patients on glucocorticoids longer than intended. Persistent disease activity, relapse during dose reduction, limited affordability or availability of glucocorticoid-sparing treatments, and difficulties implementing treatment recommendations can all contribute to continued glucocorticoid dependence.

A key bottleneck in reducing glucocorticoid use remains securing a timely referral to a rheumatologist. Delays can cause the condition of patients to worsen, potentially requiring higher doses of glucocorticoids and longer treatment courses.

A Canadian study found a median 66-day wait from referral to rheumatologist assessment for patients with systemic inflammatory rheumatic diseases, whereas a European study found that the median interval from rheumatoid arthritis symptom onset to rheumatologist assessment was 24 weeks.

These delays can make glucocorticoids particularly attractive because they often provide rapid symptom relief.

“I see a lot of primary care physicians who prescribe glucocorticoids to help patients feel better as soon as possible,” Rashmi Maganti, MD, an associate professor of immunology, allergy, and rheumatology at Baylor College of Medicine in Houston, told Medscape Medical News. “It’s not uncommon for primary care physicians to start glucocorticoids and refer the patient to a rheumatologist, only for the appointment to be months away. These patients can end up on glucocorticoids for a prolonged period and develop adverse effects.”

Glucocorticoids are intended as bridging therapy: temporary treatment to relieve symptoms until a definitive diagnosis allows disease-specific therapies to begin. However, when the underlying rheumatologic diagnosis is unclear, primary care physicians may rely on them while patients await specialist assessment. Patients also tend to want relief that is as rapid and potent as possible, placing further pressure on clinicians.

“In general, I think that primary care doctors are anxious about missing an autoimmune disease and rely on glucocorticoids too quickly and in too high doses,” Vibeke Strand, MD, adjunct clinical professor in the Division of Immunology/Rheumatology at Stanford University, Stanford, California, told Medscape Medical News.

The rapid relief glucocorticoids provide can further complicate efforts to discontinue treatment. A systematic review and meta-analysis of six randomized controlled trials found that long-term, low-dose glucocorticoids improved overall disease activity, physical function, and radiographic outcomes in rheumatoid arthritis, but long-term use remains common “despite guidelines advising against this regimen.”

“Clinicians sometimes aim to prescribe glucocorticoids for a short period, perhaps 7 days. However, patients often return saying that the glucocorticoids made them feel much better and that their symptoms worsened after stopping them,” Bernadette Siaton, MD, MEdHP, a rheumatologist and associate professor of medicine at the University of Maryland School of Medicine in Baltimore, told Medscape Medical News. “This can also happen in patients without active inflammation. Glucocorticoids seem to have an effect where many patients feel great and generally more energetic.”

What Do Guidelines Say?

In both the treatment of rheumatoid arthritis and systemic lupus erythematosus, the American College of Rheumatology recommends limiting glucocorticoids to the lowest effective dose for the shortest duration possible.

This conservative approach to glucocorticoid use is also reflected in international guidelines. For rheumatoid arthritis, the European Alliance of Associations for Rheumatology advises that short-term glucocorticoids may be considered when initiating or changing conventional synthetic disease-modifying antirheumatic drugs, but should be tapered and discontinued “as rapidly as clinically feasible.” Similarly, the Australian Living Guideline for Inflammatory Arthritis recommends against the routine use of glucocorticoids as adjunctive therapy for more than 6 months.

Glucocorticoid Use May Affect Getting to the Correct Diagnosis

Beyond the risks involved with prolonged use, glucocorticoids can mask symptoms of underlying conditions, complicating diagnosis. For example, guidance from the British Society for Rheumatology and British Health Professionals in Rheumatology suggests that symptom improvement following glucocorticoid treatment may reinforce an incorrect diagnosis of polymyalgia rheumatica and delay the recognition of other rheumatologic disorders, infections, or malignancies.

“If patients have been taking glucocorticoids for an extended period, the underlying diagnosis may be missed because both clinical examination findings and laboratory results can be altered by the effects of glucocorticoids,” Maganti said.

Accessing Rheumatology Advice

One way to curb the default use of glucocorticoids in uncertain rheumatologic cases is to strengthen communication between primary care physicians and rheumatologists. Rather than simply submitting a referral form and waiting for it to be processed, primary care physicians may choose to build a rapport with a specific rheumatologist they can consult for a second opinion on a vague presentation, helping to ensure that a high-priority case is not missed.

“I think it would be helpful for primary care doctors to have a go-to rheumatologist they can partner with, particularly if that rheumatologist is nearby, so they can discuss cases in real time. Sometimes a rheumatologist may not know how urgent a case is and therefore may not know how to prioritize it. If the patient is really sick, I can see them today,” Siaton said.

Strand agreed. “Delays or gaps in communication can result in patients being given glucocorticoids for longer periods or at higher doses than necessary. One potential solution is for primary care physicians to have a rheumatologist they can informally consult before making a referral, including asking whether glucocorticoids should be started and, if so, at what dose and for how long,” she noted.

Whether the communication is informal or formal is less important. The key is to access a rheumatologist’s opinion in as close to real time as possible, ensuring that complex cases are heard. Some health systems have electronic consultation platforms through which clinicians can submit queries and receive rapid answers, which can inform and improve clinical decision-making.

“I work within a large healthcare system where primary care physicians can consult rheumatologists electronically. They can submit questions and get guidance on which laboratory investigations to order, as well as the appropriate dose and duration of glucocorticoid treatment — anything that can help manage the patient while they wait to see a rheumatologist,” Maganti stated.

Role of Education and Feedback

One of the most effective ways to curb inappropriate glucocorticoid prescribing is through continuing medical education (CME).

“One of the things that we can do better is working on CME programs to educate [primary care providers] about long-term risks of glucocorticoids and recognizing rheumatological conditions that commonly present in primary care,” Siaton said. “We don’t expect primary care physicians to know everything about rheumatology, but if we can educate them about conditions they are likely to encounter, such as inflammatory arthritis, and how to recognize joint swelling and other signs of inflammation, that can help patients get referred to us in a more timely manner.”

There have been notable efforts to encourage better prescribing habits through CME. For example, a 2025 study found that a 1-hour online educational course combined with monthly personalized prescribing reports was associated with nearly 50% fewer inappropriate corticosteroid injections among primary care clinicians treating acute respiratory tract infections.

A 2024 online CME program improved primary care physicians’ knowledge and competence in reducing oral corticosteroid overuse and managing moderate-to-severe asthma according to clinical guidelines. In the same year, a trial involving 347 primary care physicians in China found that electronic prescribing alerts and feedback on prescribing patterns reduced inappropriate glucocorticoid prescribing.

There is also real-world evidence that better interdisciplinary coordination produces better patient outcomes. Project ECHO (Extension for Community Healthcare Outcomes), a telementoring model that connects primary care physicians with specialists through virtual, case-based learning, could help to reduce glucocorticoid overprescribing by enabling clinicians to learn best practices through obtaining rheumatologists’ advice on treatment decisions, steroid tapering, and timely referrals.

e-Consult programs in the US and Canada have been linked to shorter rheumatology waits, with roughly 40% of consults resolved without an in-person visit. In one study of a fast-track clinic for polymyalgia rheumatica, rheumatologists were able to give general practitioners taper plans for steroids.

Closing the Loop After Referral

Closer cooperation and coordination that goes beyond the formal referral process may also help to reach a shared goal of minimizing unnecessary glucocorticoid use.

In Netherlands, researchers found that joint consultations between general practitioners and rheumatologists at primary care practices were associated with a 62% reduction in annual referral rates, suggesting that closer collaboration can improve primary care management and reduce unnecessary specialist referrals.

“Ongoing communication with the primary care physician is essential. Because the primary care physician is often involved in a patient’s long-term care, when we change a medication or treatment plan, we need to close the loop and communicate it back to them, so the glucocorticoid can be adjusted and tapered appropriately. Patients also know they can contact their rheumatologist if they have a flare or need short-term glucocorticoids, rather than relying on glucocorticoids without follow-up,” Maganti said.

Maganti, Siaton, and Strand reported having no relevant disclosures.

Ryner Lai’s work examines local and regional health developments within the broader context of global policy trends and emerging ideas. His areas of interest include rare diseases, mental health, and international health policymaking.