“In just six months, more than 10% of patients on even moderate steroid regimens can develop new-onset diabetes.”
Naomi Patel, MD MPH, a rheumatologist at Massachusetts General Hospital, is at the forefront of investigating the long-term effects of glucocorticoid use in patients with systemic autoimmune diseases. Her research bridges patient care, clinical trials, and advanced simulation modeling to quantify steroid-toxicity. By capturing real-world data on toxicity, quality of life, and healthcare resource utilization, she aims to provide a clearer picture of both the personal and societal costs associated with these powerful medications.
Although an expanding arsenal of steroid-sparing agents offers promise, Dr Patel stresses that completely steroid-free regimens currently remain out of reach for many conditions. Her work is dedicated to defining the “sweet spot” of the lowest effective dose and shortest duration for each disease, to inform treatment guidelines and empower patients. Ultimately, she envisions transforming clinical practice so that toxicity is minimized without compromising disease control.
Dr Patel’s path began with an internal medicine residency at Stanford, followed by a rheumatology fellowship at Mass General Hospital. She was fascinated by the complexity of multi-organ autoimmune disorders that can be challenging to diagnose, and even more difficult to manage. She was also drawn to the idea of building lasting patient-centered therapeutic relationships and helping people take an active role in their treatment plans.
“In many diseases that we manage, glucocorticoids are still part of the standard of care of any regimen, regardless of what steroid-sparing agent you may use alongside them. Overall, in the population, there's data to show that up to 1% of the general population uses glucocorticoids long term. There are probably not too many clinic days that go by when we are not dealing with people who are currently on glucocorticoids."
Steroid-toxicity remains a critical, yet underappreciated, challenge in rheumatology.
“There are a number of very well recognized toxicities, and there are some very under-recognized toxicities… some of the things that matter most to patients don’t perfectly line up with what’s perceived to be most important by the clinician. Patients often report weight gain, mood changes, and acne, bruising, and other skin changes as being key concerns. Yet, clinicians may be more focused on toxicities that require particular treatments, such as cataracts, diabetes, and osteoporosis.”
Dr Patel believes minimizing steroid exposure is paramount, especially as for many conditions, elimination is not yet an option.
To transcend the limitations of trials and observational studies, Dr Patel has been using computer-based simulation modeling to project outcomes (relapse, infection, diabetes, renal failure, and death) across various steroid regimens and time horizons in individuals with ANCA-associated vasculitis.
“Simulation modeling is a novel way to project outcomes over longer time horizons than typical clinical trials and to study questions that may not be possible or ethical to evaluate in clinical trials.”
Certain insights include alarming rates of new-onset diabetes, even with moderate steroid-dosing regimens, underscoring the need for better risk stratification and preventive strategies.
“The LoVAS trial showed that in just six months, more than 10% of patients on even moderate steroid regimens can develop new-onset diabetes.”
Dr Patel is the Principal Investigator for the LONG-TOX (Longitudinal Glucocorticoid Toxicity in Rheumatic Disease Patients) cohort study, which is following over 100 individuals with rheumatic diseases to measure glucocorticoid toxicity using the GTI, track quality of life and healthcare resource utilization, and quantify the personal and societal burden of steroid treatment.
"We're really trying to delve into the relationships and the societal impact of glucocorticoid toxicity by measuring the relationships between GTI scores at different time points, healthcare resource utilization, and quality of life.
One of the most striking early findings is the relationship between quality of life and steroid use and steroid toxicities. That relationship is very complicated, and because of the benefits that glucocorticoids have on disease activity, the relationship between quality of life and steroid toxicities is obscured and requires further study."
Preliminary data reveal complex relationships between cumulative toxicity and patient-reported quality of life, challenging assumptions that higher toxicity uniformly translates to worse life-quality scores.
“Patients can feel isolated and unheard if concerns about their treatment are overlooked or their clinicians don’t have alternatives they can turn to. I’m keen to introduce our patients to Sam (steroidsandme.com) as I feel many would benefit from having a digital companion that can provide education, and real-world side effect tracking to bridge the gap between clinician visits and provide a deeper insight into their lived experience.”
Dr Patel emphasizes that while steroid-sparing agents are on the rise, true steroid-free regimens remain elusive for many. Her work seeks to define the optimal balance between the lowest effective dose and shortest duration across diseases, informing guidelines and empowering patients. Her ultimate goal is to transform clinical practice, minimizing toxicity without compromising disease control.
Naomi Patel, MD MPH is a practicing adult rheumatologist and clinical researcher. Dr Patel is a graduate of the David Geffen School of Medicine at the University of California, Los Angeles. She completed her Internal Medicine internship, residency, and chief resident year at Stanford and then pursued her rheumatology fellowship at Massachusetts General Hospital. Additionally, she earned a Master of Public Health degree through the Harvard T.H. Chan School of Public Health.
She enjoys seeing and working with patients in the Rheumatology Clinic with a variety of rheumatic diseases, with a specialization in vasculitis. With over 50 peer-reviewed publications in the medical literature, Dr Patel receives grant funding to conduct research in quantifying and assessing the impact of glucocorticoids in rheumatic diseases. She also serves as an Investigator in various clinical trials and conducts clinical epidemiological research to evaluate the impact of rheumatic diseases and immunosuppressive medications on the outcomes of COVID-19 infection and post-acute sequelae of COVID-19. She is an active member and participant in the American College of Rheumatology and its subcommittees.