Table 3 Experts’ propositions developed throughout 3 Delphi rounds including the strength of recommendation
PropositionSOREvidence level of data
VAS 100 (95% CI)A+B %
1 aThe adverse effects of glucocorticoid therapy should be considered and discussed with the patient before glucocorticoid therapy is started92 (85 to 100)93IV
1 bThis advice should be reinforced by giving information regarding glucocorticoid management88 (80 to 96)93IV
1 cIf glucocorticoids are to be used for a more prolonged period of time, a “glucocorticoid card” is to be issued to every patient, with the date of commencement of treatment, the initial dosage and the subsequent reductions and maintenance regimens78 (67 to 89)79IV
1Full proposition (1A+1B+1C)91 (86 to 96)92
2 aInitial dose, dose reduction and long-term dosing depend on the underlying rheumatic disease, disease activity, risk factors and individual responsiveness of the patient92 (83 to 100)86IA–III
2 bTiming may be important, with respect to the circadian rhythm of both the disease and the natural secretion of glucocorticoids74 (59 to 89)57
2Full proposition (2A+2B)83 (70 to 97)85
3When it is decided to start glucocorticoid treatment, comorbidities and risk factors for adverse effects should be evaluated and treated where indicated; these include hypertension, diabetes, peptic ulcer, recent fractures, presence of cataract or glaucoma, presence of (chronic) infections, dyslipidaemia and comedication with non-steroidal anti-inflammatory drugs92 (87 to 96)100IV
4For prolonged treatment, the glucocorticoid dosage should be kept to a minimum, and a glucocorticoid taper should be attempted in case of remission or low disease activity; the reasons to continue glucocorticoid therapy should be regularly checked81 (68 to 94)86IV
5During treatment, patients should be monitored for body weight, blood pressure, peripheral oedema, cardiac insufficiency, serum lipids, blood and/or urine glucose and ocular pressure depending on individual patient’s risk, glucocorticoid dose and duration89 (81 to 97)93IV
6aIf a patient is started on prednisone ⩾7.5 mg daily and continues on prednisone for more than 3 months, calcium and vitamin D supplementation should be prescribed95 (91 to 99)100IA
6bAntiresorptive therapy with bisphosphonates to reduce the risk of glucocorticoid-induced osteoporosis should be based on risk factors, including bone-mineral density measurement96 (92 to 99)93IB–III
6Full proposition (6A+6B)95 (89 to 100)100
7Patients treated with glucocorticoids and concomitant non-steroidal anti-inflammatory drugs should be given appropriate gastro-protective medication, such as proton pump inhibitors or misoprostol, or alternatively could switch to a cyclo-oxygenase-2 selective inhibitor91 (84 to 98)931A–IB
8All patients on glucocorticoid therapy for longer than 1 month, who will undergo surgery, need perioperative management with adequate glucocorticoid replacement to overcome potential adrenal insufficiency91 (84 to 99)93IV
9Glucocorticoids during pregnancy have no additional risk for mother and child87 (78 to 96)86IB–III
10Children receiving glucocorticoids should be checked regularly for linear growth and considered for growth-hormone replacement in case of growth impairment93 (85 to 100)93IB
  • *A+B%, percentage of the taskforce members that strongly to fully recommended this proposition, based on an A–E ordinal scale; CI, confidence interval; SOR, strength of recommendation; VAS, visual analogue scale (0–100 mm, 0 = not recommended at all, 100 = fully recommended).