EULAR evidence-based and consensus-based recommendations on the management of medium to high-dose glucocorticoid therapy in rheumatic diseases

Abstract

To develop recommendations for the management of medium to high-dose (ie, >7.5 mg but ≤100 mg prednisone equivalent daily) systemic glucocorticoid (GC) therapy in rheumatic diseases.A multidisciplinary EULAR task force was formed, including rheumatic patients. After discussing the results of a general initial search on risks of GC therapy, each participant contributed 10 propositions on key clinical topics concerning the safe use of medium to high-dose GCs. The final recommendations were selected via a Delphi consensus approach. A systematic literature search of PubMed, EMBASE and Cochrane Library was used to identify evidence concerning each of the propositions. The strength of recommendation was given according to research evidence, clinical expertise and patient preference.The 10 propositions regarded patient education and informing general practitioners, preventive measures for osteoporosis, optimal GC starting dosages, risk-benefit ratio of GC treatment, GC sparing therapy, screening for comorbidity, and monitoring for adverse effects. In general, evidence supporting the recommendations proved to be surprisingly weak. One of the recommendations was rejected, because of conflicting literature data.Nine final recommendations for the management of medium to high-dose systemic GC therapy in rheumatic diseases were selected and evaluated with their strengths of recommendations. Robust evidence was often lacking; a research agenda was created.

United States Adults Meeting 2010 American College of Rheumatology Criteria for Treatment and Prevention of Glucocorticoid‐Induced Osteoporosis

“…Comparing our results to those in other population-based cohorts, we think our results are conservative estimates of GIO risk and recommended treatment in the US (12)(13)(14)(15). The International Osteoporosis Foundation (IOF) and European Calcified Tissue Society (ECTS) working group (IOF-ECTS) and the Brazil Society for Rheumatology released GIO recommendations in 2012 with the European League Against Rheumatism (EULAR) in 2013 (49,50,51). All 4 guideline statements utilize glucocorticoid dose and duration for treatment recommendations, while the ACR, IOF-ECTS, and EULAR guidelines also use the FRAX 10-year risk of major osteoporotic fracture in their treatment determinations (30,49,50,51).…”

“…The International Osteoporosis Foundation (IOF) and European Calcified Tissue Society (ECTS) working group (IOF-ECTS) and the Brazil Society for Rheumatology released GIO recommendations in 2012 with the European League Against Rheumatism (EULAR) in 2013 (49,50,51). All 4 guideline statements utilize glucocorticoid dose and duration for treatment recommendations, while the ACR, IOF-ECTS, and EULAR guidelines also use the FRAX 10-year risk of major osteoporotic fracture in their treatment determinations (30,49,50,51). In 2013 the National Osteoporosis Guidelines Group (NOGG) in the UK released guidelines using the IOF-ECTS guidelines for Europe (52).…”

Meta‐Analysis of Tumor Necrosis Factor Inhibitors and Glucocorticoids on Bone Density in Rheumatoid Arthritis and Ankylosing Spondylitis Trials

“…A meta-analysis of 7 large prospective multinational cohorts showed that ever use of corticosteroids was associated with a 66% higher relative risk of osteoporotic fracture compared with never use of corticosteroids (5). The contribution of glucocorticoid use to osteoporosis has also been highlighted in several professional recommendations (24)(25)(26)(27). Conversely, in the context of chronic inflammatory disease, it may be that controlling inflammation can lower the risk of inflammatory bone loss.…”

The Prediction and Monitoring of Toxicity Associated with Long-Term Systemic Glucocorticoid Therapy

“…Moreover, in RA patients prescribed http://eproofing.springer.com/journals/printpage.php?token=tied1_9h6GfkA1bz4BdhSLmRr-9cVV1LwfAgIK7u4rw low-dose GC treatment (7.5 mg/day prednisolone) for 3 months, cortisol levels pre-, 30 min post-and 60 min post-ACTH test were reduced by 28%, 34% and 35 %, respectively [ 69 ]. EULAR does not currently recommend monitoring adrenal function in routine clinical practice during either low-or high-dose GC treatment [15,70]. However, it is recommended that in patients taking >7.5 mg prednisolone-equivalent daily for >3 weeks, clinicians should be aware of the risk of adrenal suppression and that a slow reduction in dose should be followed prior to cessation [ 70 ••].…”