The recommendations with strength of recommendation and level of evidence
| SOR | ||||
|---|---|---|---|---|
| Proposition | VAS; mean (95% CI) | A+B % | LoE | |
| Education and prevention | ||||
| 1 | Explain to patients (and their family and/or carers, including healthcare professionals) the aim of medium/high-dose GC treatment, and the potential risks associated with such therapy | 91 (81 to 101) | 100 | III |
| 2 | Discuss measures to mitigate such risks, including diet, regular exercise and appropriate wound care | 75 (57 to 93) | 75 | III/IV |
| 3 | Patients with, or at risk of, GC-induced osteoporosis should receive appropriate preventive/therapeutic interventions | 91 (84 to 99) | 100 | I-A |
| 4 | Patients and the patients’ treatment teams should receive appropriate, practical advice on how to manage with GC-induced hypothalamic-pituitary-adrenal axis suppression | 84 (67 to 101) | 92 | IV |
| 5 | Provide an accessible resource to promote best practice in the management of patients using medium/high-dose GCs to general practitioners | 80 (69 to 91) | 75 | IV |
| Dosing/risk-benefit | ||||
| 6 | Before starting medium/high-dose GC treatment consider comorbidities predisposing to AEs. These include diabetes, glucose intolerance, cardiovascular disease, peptic ulcer disease, recurrent infections, immunosuppression, (risk factors of) glaucoma and osteoporosis. Patients with these comorbidities require tight control to manage the risk/benefit ratio | 85 (76 to 94) | 83 | IV |
| 7 | Select the appropriate starting dose to achieve therapeutic response, taking into account the risk of undertreatment | 85 (76 to 95) | 92 | I-A/IV |
| 8 | Keep the requirement for continuing GC treatment under constant review, and titrate the dose against therapeutic response, risk of undertreatment and development of AEs | 82 (72 to 94) | 92 | IV |
| 9 | If long-term medium/high-dose GC therapy is anticipated to be necessary, actively consider GC-sparing therapy | REJECTED | ||
| Monitoring | ||||
| 10 | All patients should have appropriate monitoring for clinically significant AEs. The treating physician should be aware of the possible occurrence of diabetes, hypertension, weight gain, infections, osteoporotic fractures, osteonecrosis, myopathy, eye problems, skin problems and neuropsychological AEs | 85 (79 to 92) | 75 | IV |
A+B %, percentage of the task force members that strongly to fully recommended this proposition based on an A—E ordinal scale (A, fully recommended, B, strongly recommended); AEs, adverse effects; CI, confidence interval; GC, glucocorticoid; LoE, level of evidence (table 1); SOR, strength of recommendation; VAS, visual analogue scale (0–100 mm 0= not recommended at all, 100, fully recommended).