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presence of accurate laboratory tests and/or eye-pressure measurement equipment. Figure 2 Example of an algorithm for osteoporosis prevention in glucocorticoid users. Recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases 1563 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 variables. Furthermore, monitoring for an AE is especially useful if the AE is preventable or treatable, common, severe, and if the cost of screening is low and monitoring is feasible in daily clinical practice. Also, non-modifiable AEs should be assessed, as they could be important from the patient’s perspective and could be a surrogate marker for other AEs (eg, reflecting patient’s sensitivity to GCs), alerting the physician. A theoretical framework showing elements of the discussion on monitoring the above-mentioned AEs is found in table 5, based upon group consensus after discussing all propositions. 6. If a patient is started on prednisone >7.5 mg daily and continues on prednisone for more than 3 months, calcium and vitamin D supplementation should be prescribed. Antiresorptive therapy with bisphosphonates to reduce the risk of glucocorticoid-induced osteoporosis should be based on risk factors, including bone-mineral density (BMD) measurement. N Level of evidence: I N Strength of recommendation (95% CI): – Overall: 95 (89 to 100) – Calcium and vitamin D: 95 (91 to 99) – Bisphosphonates: 96 (92 to 99) Calcium and vitamin D supplementation have been shown to reduce GC-induced bone loss and fractures (category IA).26 27 However, they do not totally prevent GC-induced bone loss, in contrast to bisphosphonates, which have been proven superior in this respect (category IA).28 Bisphosphonate therapy can be indicated, based on the following risk factors: decreased BMD, female gender, older age, postmenopausal status and low body mass index (category IIB).29 Both GC-dose and low BMD have been shown to be predictors of fractures, but at the same BMD level, postmenopausal patients on GCs were more prone to getting fractures than postmenopausal patients without this therapy (category 1B).30 The ACR has published a clear guideline on the treatment of GC-induced osteoporosis,31 and several algorithms have been proposed to decide whether or not to start with bisphosphonates based on GC-dosage, pre-existent fractures, age and gender, menopause, and BMD measurement32 33 (fig 2 gives an example). 7. Patients treated with glucocorticoids and concomitant non-steroidal anti-inflammatory drugs (NSAIDs) should be given appropriate gastro-protective medication, such as proton pump inhibitors (PPIs) or misoprostol, or alternatively could switch to a cyclo-oxygenase-2 selective inhibitor (coxib). N Level of evidence: I N Strength of recommendation (95% CI): 91 (84 to 98) No study investigated gastro-protective measures in GCusing patients specifically, but the rationale for this proposition is given by the fact that gastro-intestinal (GI) toxicity possibly increases by treatment with GCs alone (see proposition 3). Likewise, although not studied in GC-using patients specifically, several treatment regimens have been shown to be gastroprotective for conventional NSAID users. Proton pump inhibitors (PPIs) and misoprostol reduce the risk of gastric and duodenal ulcers in patients taking conventional NSAIDs (category I B),34 35 and cyclo-oxygenase-2 inhibitors cause less GI toxicity than conventional NSAIDs in RA patients (category I B).36–38 However, conventional NSAIDs combined with PPI cause less dyspepsia
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