EXTENDED REPORTS

EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases

J N Hoes¹, J W G Jacobs¹, M Boers², D Boumpas³, F Buttgereit⁴, N Caeyers⁵, E H Choy⁶, M Cutolo⁷, J A P Da Silva⁸, G Esselens⁹, L Guillevin¹⁰, I Hafstrom¹¹, J R Kirwan¹², J Rovensky¹³, A Russell¹⁴, K G Saag¹⁵, B Svensson¹⁶, R Westhovens⁹, H Zeidler¹⁷, J W J Bijlsma¹

¹ Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, The Netherlands
² Department of Clinical Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands
³ Departments of Internal Medicine and Rheumatology, Clinical Immunology and Allergy, University of Crete, Greece
⁴ Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Germany
⁵ EULAR Social Leagues Patients’ Representative, Belgium
⁶ Sir Alfred Baring Garrod Clinical Trials Unit, Academic Department of Rheumatology, King’s College London, UK
⁷ Research Laboratory and Division of Rheumatology, Department of Internal Medicine, University of Genoa, Italy
⁸ Reumatologia, Hospitais da Universidade de Coimbra, Portugal
⁹ Department of Rheumatology, University Hospitals KU Leuven, Belgium
¹⁰ Service de Médecine Interne, Centre de Référence National "Plan Maladies Rares", Vascularites et Sclérodermie, Hôpital Cochin, Assistance Publique—Hôpitaux de Paris, Université Paris-V, France
¹¹ Department of Rheumatology, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden
¹² University of Bristol Academic Rheumatology Unit, Bristol Royal Infirmary, Bristol, UK
¹³ National Institute of Rheumatic Diseases Piest’any, Slovak Republic
¹⁴ Department of Medicine, Division of Rheumatology, University of Alberta, Edmonton, Alberta, Canada
¹⁵ Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, USA
¹⁶ Department of Rheumatology, University of Lund, Lund, Sweden
¹⁷ Devision of Rheumatology, Medizinische Hochschule Hannover, Hannover, Germany

J N Hoes, Department of Rheumatology & Clinical Immunology (F02.127), University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; mail{at}hoesjn.org

Objective: To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases.

Methods: The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist–epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference.

Results: The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment).

Conclusion: Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed.

Abbreviations: AE, adverse effect; BMD, bone-mineral density; DMARD, disease-modifying antirheumatic drug; GC, glucocorticoid; GCA, giant cell arthritis; GHR, growth-hormone replacement; NSAID, non-steroidal anti-inflammatory drug; PMR, polymyalgia rheumatica; PPI, proton pump inhibitor; RA, rheumatoid arthritis

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