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general search Type of AE Median: (25th to 75th percentiles) (AEs per 100 patient years) Cardiovascular (dyslipidemia, water and electrolyte imbalance, oedema, renal and heart dysfunction, hypertension) 15 (3 to 28) Infectious (viral, bacterial, skin infections) 15 (3 to 15) Gastro-intestinal (peptic ulcer disease, pancreatitis) 10 (4 to 20) Psychological and behavioural (minor mood disturbances, steroid psychosis) 9 (2 to 236) Endocrine and metabolic (glucose intolerance and diabetes, fat redistribution, interference with hormone secretion) 7 (3 to 34) Dermatological (cutaneous atrophy, acne, hirsutism, alopecia) 5 (2 to 80) Musculoskeletal (osteoporosis, osteonecrosis, myopathy) 4 (3 to 9) Ophtalmological (glaucoma, cataract) 4 (0 to 5) This table summarises reported AEs in studies (n = 18) of the general search of patients using GCs (n = 963) for a rheumatic disease. Only those studies of patients who were using GCs up to 30 mg prednisolone or equivalent and reporting dichotomous AE outcomes were included in the data of the table, which was used as introductory information for the taskforce. Raw data, not corrected for disease activity, co-morbidity and the frequency of AEs in the contrast group, if present, were used. So, not all AEs can be specifically attributed to the use of GCs; common events may be overestimated and less common ones underestimated. For instance, cardiovascular events are poorly correlated with GC-use. Types of AEs were divided into different groups (as has been published before25) and per group AEs per 100 patient years were derived by dividing the number of AEs by the duration of follow-up in years, times 100. The mean daily GC-dose was 8 mg, and the average duration of the studies was 19.6 months. Recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases 1561 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 Dosing strategies were assessed in one retrospective and three prospective studies on short- to intermediate-term GC treatment in polymyalgia rheumatica (PMR) and giant cell arthritis (GCA) patients needing low initial dosages had fewer relapses and lower maintenance dose, and experienced less toxicity (category III).13–16 In early RA (disease duration ,2 years), the use of low-dose GCs is based not solely on disease symptoms, but also on joint sparing effects on the long-term, as GCs can be categorised as disease-modifying antirheumatic drugs (DMARDs) (category IA).2 Different regimens with GCs have been used for joint sparing purposes in early RA, usually in combination with other DMARDs. These different schemes could result in different disease outcomes, but data are lacking. A relation between dose strategies and risk factors, such as diabetes, hypertension and osteoporosis, can only be shown indirectly (category IIB–III).17–20 It is unknown whether an individual response on the same GC-dose is different among individuals, since no study was found on the relation between dose strategies and individual responsiveness of patients. The timing of GC-administration might influence its efficacy, as both signs and symptoms (such as morning stiffness) of RA21 as well as serum levels of several pro-inflammatory cytokines22 Table 3 Experts’ propositions developed throughout 3 Delphi rounds including the strength of recommendation Proposition SOR Evidence VAS 100 (95% CI) A+B % level of data 1 a The adverse effects of glucocorticoid therapy should be considered and discussed with the patient before glucocorticoid therapy is started 92 (85 to 100) 93 IV 1 b This advice
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