Glucocorticoids (hormones) are necessary for life support and have important effects on protein, sugar, fat, water, electrolyte metabolism and the functions of various tissues and organs. Supraphysiological amounts of glucocorticoids have a variety of pharmacological effects, including anti-inflammatory, anti-allergic and immunosuppressive effects, and are widely used in clinical practice. Hormones can alleviate many clinical conditions and often have a “fast-acting” effect. Hormones are among the most widely used drugs in clinical practice, and there is hardly a clinician who is not familiar with their use. Yet, hormones are a controversial drug. Their remarkable efficacy and serious side effects, as well as their hormonal dependence, make clinicians and patients “love and hate” hormones. Some people call them the “opium” of rheumatic diseases. The incorrect or unreasonable use of hormones is very common in clinical practice, especially in patients with rheumatic diseases without regular treatment, which not only causes damage to patients’ bodies, but also brings burden to society. However, the application of hormones is necessary for some diseases, so the indications and contraindications should be clearly grasped in the process of use. Indications for hormones: Diseases requiring hormone therapy mainly include: primary or secondary hyperalgesia; various types of adrenal hyperplasia caused by defects in the enzymes required for the synthesis of glucocorticoids; autoimmune diseases: such as systemic lupus erythematosus, vasculitis, polymyositis, dermatomyositis, Still disease, Graves’ eye disease, autoimmune hemolysis, thrombocytopenic purpura, thrombocytopenic epilepsy, and other diseases. thrombocytopenic violet epilepsy, myasthenia gravis; allergic diseases, such as severe bronchial asthma, anaphylaxis, serum sickness, atopic reactive dermatitis; organ transplant rejection, such as kidney, liver, heart, lung and other tissue transplants; inflammatory disorders, such as segmental ileitis, ulcerative colitis, inflammatory eye disease; hematologic diseases, such as acute leukemia, lymphoma; other: nodular disease, thyroid crisis, subacute non pyogenic thyroiditis, septic shock, cerebral edema, nephrotic syndrome, hypercalcemia. Here we focus on the application of hormones in common rheumatic diseases. 1. Systemic lupus erythematosus: hormone is a common drug for the treatment of SLE. Clinically, the dosage and course of hormone should follow the principle of individualization, depending on the specific condition of the patient, to the extent that it can control the clinical symptoms and improve the degree of vasculitis. In 1999, the American College of Rheumatology (ACR) guidelines for the treatment of SLE suggested that patients with mild disease usually do not need long-term oral hormone therapy, and some patients only need small doses or Some patients require only low-dose or alternate-day hormones (prednisone ≤10 mg/d) for relief. For patients with severe SLE, such as those with active lupus nephritis or severe thrombocytopenia, high-dose hormone therapy is required, with oral prednisone 40-60 mg/d or intravenous methylprednisolone 1 g/d for 3 days, depending on the patient’s condition and systemic status. There is no consensus on the dosage of hormones for neuropsychiatric lupus (NPSLE), and there is a lack of evidence to support whether methylprednisolone less than 800 mg/d is equally effective. It is important to note that long-acting hormone therapy such as dexamethasone should not be used in patients with SLE to avoid the resulting adverse effects. In summary, hormone is still the first choice for SLE treatment, but should not be used in large doses and long courses, but should be reduced as soon as possible after the control of symptoms and improvement of the patient’s general condition, and timely addition of immunosuppressive drugs. 2, vasculitis: is a group of diseases with avascular necrosis and inflammation as the main pathological changes of the body can be involved in various parts of the blood vessels, because of the different vessels affected, the prognosis is also different. In terms of treatment, the current view is that hormone is still the drug of choice, in the induction of remission, usually with hormone combined with CTX or MTX treatment, to be in remission hormone reduction, the reduction process should be slow, to prevent relapse; in remission treatment to immunosuppressants as the main, can also be combined with a small amount of hormone therapy, which is conducive to reducing the relapse rate of the disease; for relapsing patients should pay attention to increase the amount of hormone For patients with relapse, we should pay attention to increase the amount of hormone to control the disease as soon as possible. In summary, hormone is a very important drug in the treatment of vasculitis, but attention should be paid to adjust the dosage of drugs according to the needs of the disease. 3.Adult Still’s disease: At present, it is believed that hormone is still the main drug for this disease, and its efficiency is 76%-95%. For most patients, the general starting dose of prednisone is 0.5-1.0 mg/kd/d, and some patients need 1-2 mg/kg/d to be effective. A sufficient amount of glucocorticoids can control the symptoms of fever, rash and arthralgia on the second day or within a week, and the enlarged liver, spleen and lymph nodes are shrinking, but it often takes 2 weeks to 1 month or even longer for the white blood cell count and blood sedimentation to return to normal. The dose of prednisone should be reduced slowly after the disappearance of symptoms and the normalization of laboratory indicators, with 2.5-5mg every 1-2 weeks. It is generally believed that the early dose should be sufficient, and if necessary, intravenous shocks such as methylprednisone or hydrocortisone can be applied at the beginning of treatment to treat patients with acute illnesses, and then switched to oral preparations after the condition is stabilized and maintained for a longer period of time. Early and rapid dose reduction may lead to relapse of the disease. Occasional fever during the hormone treatment period or dose reduction period can be temporarily added with non-steroidal anti-inflammatory drugs with small adverse effects. 4, rheumatic polymyalgia: glucocorticoid is the preferred treatment drug, but the dosage is mainly in small doses, the general dosage is prednisone 5-20mg/day: the symptoms will improve significantly within a week, and the blood sedimentation and c-reactive protein will gradually return to normal. For patients with severe disease, fever, myalgia and restricted activities: Prednisone 15-30mg/day, with the improvement of symptoms, blood sedimentation close to normal can start to gradually reduce the amount, maintenance amount 5-10mg/day, maintenance time should last 6-12 months. Most patients can stop using hormones within 2 years, and a few patients need to maintain small amounts for many years. 5, rheumatoid arthritis: hormone is not the first choice of drugs for RA. Moreover, most patients with RA do not need hormone therapy. Generally speaking, the correct use of NSAIDs in combination with DMARDs can keep the disease under control in most patients. Hormones are only considered as a transitional treatment for a small number of patients in whom NSAIDs combined with DMARDs are not effective or are not tolerated. Moreover, even if the patient belongs to the indication of hormone, small doses should be used as much as possible and the dose should be reduced or stopped as soon as possible. In addition, some foreign countries advocate the long-term administration of small doses of hormones to RA patients, but this has not been widely accepted by the academic community. It is also believed that in some patients with recurrent joint effusion, intra-articular injection of trimethoprim may be used to promote remission of the disease. However, in principle, the interval between two intra-articular injections should be no less than 3 months. Adverse reactions of hormones Although hormones have good efficacy and low price, the adverse reactions of hormones also discourage people. The main adverse reactions include: impairment of adrenal cortical function, osteoporosis and spontaneous fracture, effects on growth and development and reproductive function of children, induction and aggravation of infection, induction and aggravation of diabetes, ulcer, aseptic osteonecrosis, and behavioral and mental abnormalities. Scientific use of medication How to use medium-acting hormones scientifically in order to achieve better anti-inflammatory efficacy and reduce side effects at the same time? First of all, we must understand the physiological curve of our own hormone secretion: 0-2 o’clock is the trough of hormone level, and 8 o’clock in the morning is the peak of hormone level. If the exogenous hormone disrupts the physiological trough in the middle of the night, it will not produce the peak at 8 o’clock the next morning. Therefore, it is wrong to take one oral dose of an intermediate-acting hormone at night before bedtime. NSAIDs should be used for the treatment of rheumatologic patients to address nocturnal pain. Oral administration of medium-acting hormones three times a day can also seriously disrupt the regularity of one’s own hormone production, and long-term use can damage the hypothalamic-pituitary-adrenal axis. If you plan to use hormones for a longer period of time, try not to take oral hormones three times a day, but instead take a once-daily dose of a mid-acting hormone at around 8 a.m., the peak time of the hormone physiological curve. Combining the two daily doses and taking a single dose at 8:00 a.m. on alternate days will cause less damage to the hypothalamic-pituitary-adrenal axis, but will also be relatively less effective. Therefore, in the acute phase of the disease, then once daily if possible. Alternate-day oral medium-acting hormones are not advocated for application at the beginning of treatment, but are used as a maintenance treatment phase after the disease is controlled. Precautions for hormone use 1. Use during pregnancy: Glucocorticoids can pass through the placenta. The use of pharmacological doses of glucocorticoids in humans may increase the incidence of placental insufficiency, neonatal weight loss or stillbirth. Teratogenic effects on humans have not been demonstrated. Infants who have received certain doses of glucocorticosteroids during pregnancy should be monitored for signs of hyperalgesia. 2. Use during lactation: Physiological doses or low pharmacological doses (25 mg of cortisone or 5 mg of prednisone per day or less) generally have no adverse effects on the infant. However, if the lactating mother receives pharmacologically high doses of glucocorticoids, she should not breastfeed, because glucocorticoids can be excreted in milk and cause adverse effects on the infant, such as growth inhibition and suppression of adrenal cortical function. 3, pediatric medication: long-term use of adrenocorticotropic hormones in children requires great caution, because hormones can inhibit the growth and development of the child, and if long-term use is necessary, short-acting (such as cortisone) or medium-acting preparations (such as prednisone) should be used, and long-acting preparations (such as dexamethasone) should be avoided. Growth inhibition may be reduced by alternate-day therapy with oral intermediate-acting preparations. The risk of osteoporosis, ischemic necrosis of the femoral head, glaucoma and cataract in children or adolescent patients must be closely observed for long term use of glucocorticoids. 4. Geriatric use: Geriatric patients are prone to hypertension with glucocorticoids. Elderly patients, especially post-menopausal women, are prone to osteoporosis when applying glucocorticoids. 5. Glucocorticoids and infection: On the one hand, non-physiological glucocorticoids are detrimental to anti-infection. Physiological doses of adrenocorticotropic hormone can improve the resistance to infection in patients with hypoadrenocorticism. Non-hypoadrenocortical patients receiving pharmacological doses of glucocorticosteroids are prone to infections because the patients’ original diseases have often weakened the cellular and/or humoral immune functions, and long courses of supraphysiological doses of corticosteroids have weakened the patients’ inflammatory response, cellular immunity and humoral immune functions, and the pathogenic bacteria invaded by the skin and mucous membranes cannot be controlled. Under the effect of hormones, infections that have been controlled can become active, most often as a recurrence of tuberculosis infection. But on the other hand, in some infections, the application of hormones can reduce the destruction of tissues, reduce exudation, reduce the symptoms of infection poisoning, but must be treated with effective antibiotics at the same time, closely observe the changes in the condition, after a short period of use, that is, the dose should be quickly reduced, discontinued. 6, the following conditions should be used with caution: heart disease or acute heart failure, diabetes, diverticulitis, emotional instability and psychotic tendencies, systemic fungal infections, glaucoma, hepatic impairment, ocular herpes simplex, hyperlipoproteinemia, hypertension, hypothyroidism (when the role of glucocorticoids is enhanced), myasthenia gravis, osteoporosis, gastric ulcer, gastritis or esophagitis, renal impairment or stones Tuberculosis, etc. 7. Glucocorticoids should not be used in the following cases: severe psychiatric history, active gastric and duodenal ulcers, recent post-operative gastrointestinal anastomosis, severe osteoporosis, obvious diabetes, severe hypertension, viral, bacterial and mycobacterial infections that cannot be controlled with antibacterial drugs. 8. Follow-up examination: Those who apply glucocorticosteroids for a long time should have the following items checked regularly: ① blood sugar, urine sugar or glucose tolerance test, especially for those with diabetes or diabetic tendency; ② children should be monitored regularly for growth and development; ③ ophthalmic examination, paying attention to the occurrence of cataract, glaucoma or eye infection; ④ serum electrolytes and fecal occult blood; ⑤ examination of hypertension and osteoporosis, especially for the elderly.