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therapy is started. This advice should be reinforced by giving information regarding glucocorticoid management. If glucocorticoids are to be used for a more prolonged period of time, a ‘‘glucocorticoid card’’ is to be issued to every patient, with the 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 antiinflammatory drug; PMR, polymyalgia rheumatica; PPI, proton pump inhibitor; RA, rheumatoid arthritis 1560 www.annrheumdis.com on November 15, 2021 by guest. Protected by copyright. http://ard.bmj.com/ Ann Rheum Dis: first published as 10.1136/ard.2007.072157 on 27 July 2007. Downloaded from date of commencement of treatment, the initial dosage and the subsequent reductions and maintenance regimens. N Level of evidence: IV N Strength of recommendation (95% CI): – Overall: 91 (86 to 96) – Pretreatment advice: 92 (85 to 100) – Information: 88 (80 to 96) – Glucocorticoid card: 78 (67 to 89) We recommend that the frequency of AEs during GC-therapy (table 2) should be categorised following WHO guidelines: very common (.1/10 patients); common (.1/100); uncommon (.1/1000); rare (.1/10 000); very rare (,1/100 000).5 Detailed discussion of common and very common AEs of therapy is an integral part of the management of any disease and of patient education. Because patients’ perspectives on AEs might differ from doctors’ perspectives, patient information should include both perspectives (category IV evidence). In a population-based cohort, 68% of patients who used GCs recalled discussing potential GC-related AEs with their practitioner.6 This recall might be influenced by the perception of severity of GC-related AEs, which may differ among patients.7 Whether discussion of possible AEs before GC-therapy has any beneficial effect on disease outcome—for example by improving patient compliance—is unclear because of lacking data. However, general patient education, including discussing possible AEs of other treatment, positively influences outcome of therapy.8–11 In contrast, in a controlled clinical study the knowledge about AEs of beta-blockers produced anxiety.12 So, in giving information, individual patient psychological characteristics should be taken into account. The format of patient education—for example the use of information leaflets—has not been investigated in long-term GC-therapy, so this part of the recommendation is also supported by expert opinion only. Likewise, no evidence was found to support the use of ‘‘glucocorticoid cards’’, but the use of a pocket card in methotrexate (MTX) users improved patients’ knowledge on safety and toxicity of MTX.9 2. Initial dose, dose reduction and long-term dosing depend on the underlying rheumatic disease, disease activity, risk factors and individual responsiveness of the patient. Timing may be important, with respect to the circadian rhythm of both the disease and the natural secretion of glucocorticoids. N Level of evidence: I–III N Strength of recommendation (95% CI): – Overall: 83 (70 to 97) – Dose regimens: 92 (83 to 100) – Dose timing: 74 (59 to 89) Table 1 Levels of evidence I-A Meta-analysis of randomised controlled trials I-B Randomised controlled trial II-A Controlled study without randomisation II-B Quasi-experimental study III Descriptive studies (comparative, correlation, case-control) IV Expert committee reports/opinions and/or clinical opinion of respected authorities Figure 1 Different study populations of the included studies from the general search. Table 2 Reported AEs in GC-treated patients with rheumatic diseases: results of the
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