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and considered for growth-hormone replacement in case of growth impairment. 1564 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 N Level of evidence: I N Strength of recommendation (95% CI): 93 (85 to 100) GCs can cause growth retardation in children (category I B).66–69 The pathogenesis of this growth impairment is multifaceted. Growth-hormone replacement (GHR) can be used to prevent growth impairment due to GCs: an increase in linear growth with GHR was shown in several studies of GC-using JIA patients (category I–III),70–75 and in studies of ‘‘slowly growing GC-treated patients’’ (category II).76 77 The daily GC-doses used in these studies varied between 0.2 and 0.5 mg/kg prednisolone equivalent, and the duration GHR therapy was 2–4 years. If GHR is considered, referral to an experienced paediatrician is indicated (category IV evidence), and additional testing can confirm growth-hormone deficiency. Routine usage of GHR in GC-using patients is hampered by several factors: the therapy involves daily injections (subcutaneously or intramuscularly), the length gain is relatively small, and it is a very costly therapy (between J15 000 and J50 000 annually, depending on the weight of the individual child78). DISCUSSION This EULAR document on the safer use of systemic GCs in rheumatic diseases used a similar design to that of earlier EULAR taskforces,79–82 i.e. a combination of both evidence and expert opinion. The added value of this taskforce, like previous ones, is provided by the fact that they (1) are a broad representation of experts in the field of GCs within and outside Europe; (2) use recent research data; and (3) use a thorough evidence-based format. The order of 10 propositions in the paper does not reflect importance, but more or less the logical order of patient management. Both the level of evidence of each proposition and the strength of recommendations are given. This approach has led to a reduction of personal bias, good external validity and generalisability, and clear identification of areas of clinical practice where more research data are required.83 The propositions promote the safer use of GCs among physicians and patients alike in daily clinical practice, and they will form the basis of further EULAR research and education. These recommendations have some limitations. Since GCs are used quite extensively, the search results were often overwhelming. To overcome this, we used more specific search strategies in which relevant studies might have been overlooked. Second, the selection of circumstantial evidence in the absence of direct evidence has some degree of subjectivity. Third, in the literature, the evidence hierarchy has focused on treatment efficacy, whereas evidence on safety might be better graded by other study types than RCTs. Other grading systems might be preferred for grading future studies on safety. The literature search showed that studies on GCs in general lack a systemic assessment of AEs and that AEs often are poorly described, let alone defined, which made it difficult to provide direct evidence for most propositions. It is therefore advisable to monitor a well-defined list of AEs in a standardised manner in future studies, taking into account patients’ perspectives, but standardised scoring for most AEs has yet to be developed. Hypertension, diabetes, osteoporosis, gastric ulcer, cataract, glaucoma, infections, and dyslipidaemia are AEs that merit monitoring. To point out the most important topics for future research on GCs, a research agenda of 11 research questions has been
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