“While some steroid-toxicities can be mitigated by tapering the drug back, a lot of the side effects are very long lasting. Steroids are like radiation, the best amount of exposure is no exposure.”
Max Hamburger MD. is a leading private practice rheumatologist and founder of United Rheumatology - a rheumatology care management organization leading in the development of value-based precision medicine. In 2022 he was recognized by the American College of Rheumatology (ACR) as an ACR Master - one of the highest honors the College bestows on those “who have made outstanding contributions to the ACR and the field of rheumatology”.
Dr Hamburger had an early introduction to the world of rheumatology as his father developed very severe rheumatoid arthritis when he was a young teenager. During his time in medical school at the Albert Einstein College of Medicine in New York City, he made the acquaintance of Peter Barland MD., who was a practicing rheumatologist and is now Professor Emeritus of the Department of Medicine (Rheumatology), and of the Department of Pathology at Einstein. He asked Dr Barland to take over the care of his father who ended up seriously disabled by the disease, needing hip replacements, and sadly passed away after years of care at the age of 71.
Dr Hamburger took the opportunity to conduct a research project in Dr Barland’s laboratory, which was so successful he spent more time in his laboratory as a senior medical student. The collaboration yielded several publications and sparked Dr Hamburger’s fascination with immunology.
This led Dr Hamburger to finish his training at the National Institutes of Health (NIH), in the Institute of Allergy and Infectious Disease, working with Dr Anthony Fauci. While Dr Hamburger found studying the immune system and its response to infection intriguing, “I found immunology and its expression in rheumatology the most interesting”. During the course of his career he has authored or co-authored some 50 plus scientific publications and looked after countless patients.
“Over the past 43 years I’ve been in private practice and seen the management of patients with rheumatic diseases evolve enormously. When I started back in 1976, we had almost no drugs that were specific for our patients, and the drug that we probably depended on the most was glucocorticoids. There are videos of patients with rheumatoid who were wheelchair bound and when they were given steroid injection, they were able to get up and walk across the stage. The benefits of these drugs are remarkable.”
“Sadly it didn't take long for physicians to discover that steroid-toxicity is almost linearly related to the potential value of these drugs.”
He continues by explaining:“in terms of therapeutic challenges, managing steroids and steroid-toxicity is probably the single biggest challenge we face today. We can give people steroids such as prednisone and relieve a lot of their symptoms. Once we start a patient on these medications they often feel great in the short term, but we know we are creating long-term side effects.“
Dr Hamburger explains that despite the launch of numerous biologics and other immunomodulatory therapies, for a lot of patients there still aren't specific medications, so patients are often prescribed glucocorticoids - partly because all clinicians succumb to the desire to help their patients.
Once prescribed oral glucocorticoids for a rheumatoid disease, Dr Hamburger explains, patients really should be referred to a specialist rheumatologist. However, accessibility is often a challenge as there is a 40% shortfall in the number of practicing rheumatologists in the U.S. versus the need. This can lead to months of waiting and in the meantime, the general practitioner will have started the patient on oral glucocorticoids. And while some side effects such as depression or mania hit quite quickly, generally people feel energized during the first few months of treatment. It's only after a year or two that the more vexing side effects start to show.
“If a patient is suffering the primary care physician isn’t going to leave them just sitting there waiting for relief, they will generally put you on prednisone, and by the time an appointment comes up 3 to 4 months later, the patient will be feeling a lot better, and if they’ve gotten away with a lower dose then the patient may not be experiencing the side effects yet.”
“Lots of drugs have side effects, but generally when the drugs are stopped the side effects go away. With steroids, by the time a patient is experiencing side effects, they’ve been changed physically - whether that's the formation of cataracts of the eye, loss of bone, or the onset of diabetes.”
“While some steroid-toxicities can be mitigated by tapering the drug back, a lot of the side effects are very long-lasting. Steroids are like radiation, the best amount of exposure is no exposure.”
A key challenge Dr Hamburger highlights is that tapering steroids isn't easy, and part of that is the patient sees the benefit before they feel the impact of the damage they are doing. He heralds the development of the Steritas Glucocorticoid Toxicity Index (GTI) as being game changing in terms of helping provide a risk score that patients can identify with.
“The GTI gives us a number and patients recognize the importance of a number, and when you go to try and change the dose, you can say to them “this is your number now and this is your risk, and we need to try to get that down. This is your risk and they really respond to that.”
Dr Hamburger suggests the GTI will also be helpful in making the case for patients to receive more expensive therapeutics, noting that one of the key biologic drugs in a rheumatologist’s arsenal is Humira (adalimumab) which was the world’s biggest selling drug in 2021, with global revenues for manufacturers AbbVie and Eisai topping $21.18 billion that year alone.
Dr Hamburger concludes, “I think the GTI is critical to improving the health of a great number of patients. I can't imagine anybody not putting their shoulder behind this now, because this will benefit more patients than any other single thing that we do because it'll touch every patient on steroids.”