29/03/2026
Steroids: The Comfort We Prescribe, The Cost We Ignore
Rampant steroid use in rheumatoid arthritis is no longer the elephant in the room. It is the room.
Let us be clear. Glucocorticoids are brilliant drugs. In the right setting they are nothing short of magical. A patient crippled with inflammation walks in and walks out feeling human again. Few interventions in medicine offer that kind of instant gratification. Steroids do.
And that is exactly the problem.
Because what begins as a rescue quietly becomes routine. Then routine becomes habit. And habit, in some practices, has become policy.
Across clinics, one still meets patients who have been on “just 5 mg” for years. It is always “just” 5 mg. Occasionally 10 on bad days. Nobody quite remembers when it started. The joints are comfortable, the patient is happy, the follow up is predictable. From the outside, it looks like good medicine.
Until you look a little closer.
The science has not been ambiguous. Recommendations from EULAR and ACR have repeated the same line with almost boring consistency. Use steroids if you must, but use them briefly, sparingly, and always as a bridge. They are not a substitute for disease modifying therapy. They do not halt structural damage in any meaningful way when used like this. What they do, very efficiently, is buy short term peace at the cost of long term problems.
And those problems are not rare side notes in textbooks.
We have all seen them. The well controlled arthritis patient with blood sugars that refuse to listen. The unexpected fracture after a trivial fall. The hip that gives way because of avascular necrosis. The face that slowly rounds, the blood pressure that slowly rises, the infection that arrives uninvited. None of these patients were told they were on a “long term experiment.”
They were just “maintained.”
There is also an uncomfortable truth we do not say out loud. Steroids make clinics look good. Patients feel better quickly. They smile more. They come back. The consultation is smooth. Compare that with the slow, sometimes frustrating journey of optimising DMARDs, adjusting doses, monitoring labs, explaining why relief is not immediate. One path is gratifying. The other is correct.
Too often, we choose gratifying.
To be fair, this is not ignorance. Indian rheumatology is full of sharp, well trained minds. This is culture. It is inertia. It is learned behaviour. When senior names normalise long term steroids, the next line follows, sometimes unconsciously. The patient, of course, votes for the drug that works overnight.
But rheumatology was never meant to be a practice of overnight victories.
We now have the tools. Methotrexate when used properly is still a remarkably effective drug. Combination conventional DMARDs work. Biologics and targeted therapies have changed expectations entirely. Treat to target is not aspirational anymore. It is achievable.
Steroids were meant to help us get there. Not to replace the journey.
In clinic, the hardest conversations are not about starting therapy. They are about undoing it. Tapering long standing steroids feels almost like betrayal to some patients. “Doctor, I was fine till now.” Yes, you were comfortable. That is not always the same as being well. Rebuilding that understanding takes time, and sometimes costs goodwill.
Which is perhaps why it is easier not to try.
This is not a call out of individuals. It is a nudge to the system. The next generation of rheumatologists in India has a choice. Continue a model that prioritises immediate comfort, or build one that respects long term outcomes even when it is less glamorous.
Some will be offended. That is alright. Steroids, after all, are excellent at suppressing inflammation. They are less effective at addressing discomfort of another kind.
And if, years from now, a patient walks into our clinic pain free but walks out with complications we helped create, we should at least have the honesty to admit one thing.
We did not treat the disease.
We negotiated with it.
