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Defining conditions where long-term glucocorticoid treatment has an acceptably low level of harm to facilitate implementation of existing recommendations: viewpoints from an EULAR task force
  1. Cindy Strehl1,
  2. Johannes W J Bijlsma2,3,
  3. Maarten de Wit4,
  4. Maarten Boers3,5,
  5. Nele Caeyers6,
  6. Maurizio Cutolo7,
  7. Bhaskar Dasgupta8,
  8. William G Dixon9,
  9. Rinie Geenen10,
  10. Tom W J Huizinga11,
  11. Alison Kent12,
  12. Annette Ladefoged de Thurah13,
  13. Joachim Listing14,
  14. Xavier Mariette15,16,
  15. David W Ray17,
  16. Hans U Scherer11,
  17. Raphaèle Seror15,16,
  18. Cornelia M Spies1,
  19. Simon Tarp18,
  20. Dieter Wiek19,
  21. Kevin L Winthrop20,
  22. Frank Buttgereit1
  1. 1Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin, Germany
  2. 2Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands
  3. 3Amsterdam Rheumatology& Immunology Center, VU University Medical Center, Amsterdam, the Netherlands
  4. 4Medical Humanities, VU Medical Centre, Amsterdam, the Netherlands
  5. 5Department of Epidemiology & Biostatistics, VU University Medical Center, Amsterdam, the Netherlands
  6. 6Patient Research Partner, Mol, Belgium
  7. 7Department of Internal Medicine, Research Laboratory & Academic Division of Clinical Rheumatology, University of Genoa, Genova, Italy
  8. 8Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, Essex, UK
  9. 9Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester, UK
  10. 10Department of Clinical & Health Psychology, Utrecht University, Utrecht, the Netherlands
  11. 11Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
  12. 12Salisbury Foundation Trust NHS Hospital, Wiltshire, UK
  13. 13Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
  14. 14Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
  15. 15Department of Rheumatology, Assistance Publique–Hopitaux de Paris, Hôpitaux Universitaires Paris-Sud, Le Kremlin Bicêtre, France
  16. 16Université Paris-Sud; INSERM U1184, Le Kremlin Bicêtre, France
  17. 17Faculty of Medical and Health Sciences, University of Manchester, Manchester, UK
  18. 18Department of Rheumatology, The Parker Institute, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark
  19. 19Deutsche Reuma-Liga, Bonn, Germany
  20. 20Divisions of Infectious Diseases, Oregon Health & Science University, Portland, USA
  1. Correspondence to Dr Cindy Strehl, Department of Rheumatology and Clinical Immunology, Charité University Hospital, Charitéplatz 1, Berlin 10117, Germany; cindy.strehl{at}charite.de

Abstract

There is convincing evidence for the known and unambiguously accepted beneficial effects of glucocorticoids at low dosages. However, the implementation of existing recommendations and guidelines on the management of glucocorticoid therapy in rheumatic diseases is lagging behind. As a first step to improve implementation, we aimed at defining conditions under which long-term glucocorticoid therapy may have an acceptably low level of harm. A multidisciplinary European League Against Rheumatism task force group of experts including patients with rheumatic diseases was assembled. After a systematic literature search, breakout groups critically reviewed the evidence on the four most worrisome adverse effects of glucocorticoid therapy (osteoporosis, hyperglycaemia/diabetes mellitus, cardiovascular diseases and infections) and presented their results to the other group members following a structured questionnaire for final discussion and consensus finding. Robust evidence on the risk of harm of long-term glucocorticoid therapy was often lacking since relevant study results were often either missing, contradictory or carried a high risk of bias. The group agreed that the risk of harm is low for the majority of patients at long-term dosages of ≤5 mg prednisone equivalent per day, whereas at dosages of >10 mg/day the risk of harm is elevated. At dosages between >5 and ≤10 mg/day, patient-specific characteristics (protective and risk factors) determine the risk of harm. The level of harm of glucocorticoids depends on both dose and patient-specific parameters. General and glucocorticoid-associated risk factors and protective factors such as a healthy lifestyle should be taken into account when evaluating the actual and future risk.

  • Corticosteroids
  • Rheumatoid Arthritis
  • Osteoporosis
  • Infections
  • Cardiovascular Disease

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