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data directly support the proposition. Circumstantial: no data directly or indirectly support the proposition, but there are circumstantial data which are useful to the proposition. Partially direct: part of the proposition is directly supported by data. 1562 Hoes, Jacobs, Boers, et al 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 show a circadian rhythm with a flare at the beginning of the day. Administration of GCs early in the morning23 (category IB), or the use of modified release tablet of prednisone, delivering the GC early in the morning (abstract)24 gave more improvement of RA symptoms than conventional timing of GCtherapy. In conclusion, there is category III evidence on dosing regimens of GCs in PMR/GCA and category IA evidence showing a benefit for the use of low-dose long-term GCs in early RA. The relation between risk factors, AEs, high GCdosages and long-term GC-use was indirectly shown for diabetes (category IIB) and hypertension (category III). No study was identified on individual responsiveness to GC (category IV). There are category IB data on a superior effect of circadian administration of GCs. 3. When 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, dyslipidemia and comedication with non-steroidal anti-inflammatory drugs. N Level of evidence: IV N Strength of recommendation (95% CI): 92 (87 to 96) Even though the above-mentioned risk factors for GCassociated AEs are well known,25 and there is obvious face validity trying to prevent these from occurring by assessing and treating comorbidities and risk factors at baseline, there is no evidence to show that this is effective (category IV). 4. For 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 checked regularly. N Level of evidence: IV N Strength of recommendation (95% CI): 81 (68 to 94) This proposition is supported by expert opinion alone, although this proposition has obvious face validity, since the occurrence of GC-related AEs, osteoporosis in particular (proposition 5 and 6), is dependent on dose and duration of therapy. 5. During 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 duration. N Level of evidence: IV N Strength of recommendation (95% CI): 89 (81 to 97) There is no direct evidence from appropriately designed studies to support this proposition (category IV). Since risks of AEs during GC-treatment are related to GC-dose and duration of treatment, monitoring should be dependent on both Table 5 Theoretical framework of criteria which can be used to decide whether monitoring for specific AEs is useful No. needed to screen? (1/prevalence per year) Severity? (Low/moderate/high) Cost of screening? (Low/moderate/high) Feasibility of scoring? (Low/moderate/high) Body weight 1.5 6 Low Low High Blood pressure ? Moderate Low High Peripheral oedema ? Low Low High Heart failure ? High Moderate Moderate* Dyslipidemia ? Moderate Moderate Moderate* Blood/urine glucose 12.5 6 Moderate Moderate High Glaucoma 18.1 84 Moderate Moderate Moderate* *Scoring in daily practice depends on
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