[Endgame of glucocorticoid therapy in rheumatic diseases: Slay or Stay?]

Abstract

Glucocorticoids have played a central role in treating rheumatic diseases since their introduction in the mid-20th century, owing to their anti-inflammatory and immunosuppressive effects. However, prolonged glucocorticoid exposure is closely associated with adverse outcomes, including organ damage, metabolic disturbances, osteoporosis, and infection, making long-term glucocorticoid management a major clinical challenge. With the emergence of targeted therapies and novel immunotherapies, the rheumatology community has increasingly debated 'Slay or Stay' in glucocorticoid management:'Slay' refers to tapering and discontinuing glucocorticoids whenever feasible after disease control, aiming for glucocorticoid-free remission, while 'Stay' emphasizes maintaining low-dose glucocorticoids in selected patients to sustain remission and reduce relapse risk. This review summarizes recent international guidelines and representative clinical trials and discusses glucocorticoid tapering and withdrawal strategies in major rheumatic diseases, including systemic lupus erythematosus, rheumatoid arthritis, and systemic vasculitis. Overall, glucocorticoid management should not be viewed as an absolute choice between 'Slay' and 'Stay', but should balance disease control and long-term safety through individualized tapering based on relapse risk and glucocorticoid-related toxicity.