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the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference. Results: The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment). Conclusion: Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed. S ince 1948, glucocorticoids (GCs) have been widely used in medicine.1 Although GCs soon became associated with the occurrence of adverse effects (AEs), they are still the most frequently used anti-inflammatory and immune-suppressive drugs in rheumatic diseases. Recent studies have demonstrated the disease-modifying potential of low-dose GCs in rheumatoid arthritis (RA) and this has renewed the debate on the risk– benefit ratio of this treatment.2 Current literature on the risk– benefit ratio of GCs is nevertheless inconsistent, and inappropriate use of GCs could lead to increased toxicity;3 this emphasises the need for clear statements on proper use of GCs. Hence, a EULAR task force on GCs, including a patient, was formed to develop evidence-based recommendations, to provide a tool for the better use and management of GC-therapy in rheumatic diseases. METHODS Endorsed by EULAR-ESCISIT, a multidisciplinary guideline development committee on GCs was formed, consisting of 20 experts in the field of GCs from 11 European countries, Canada and the USA: 15 rheumatologists, 1 internist, 1 rheumatologist–epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the risk–benefit ratio of GCs, and EULAR standardised operating procedures4 were then followed: (1) to identify and critically appraise research evidence for the 10 propositions, performing a systematic literature search of PUBMED, EMBASE, CINAHL and Cochrane Library; (2) to generate and validate recommendations based on the best available evidence, according to research, clinical expertise and perceived patient preference (levels of evidence are defined in table 1); and (3) to formulate a future research agenda. RESULTS First, a general literature search was performed (appendix 1 of the full version of the article; available web-only at http://www.annrheumdis.com/supplemental), including the estimated incidence of different types of AEs as derived from studies reporting on frequencies of AEs of GCs (see fig 1 and table 2). Second, after the taskforce experts had discussed the results of this general literature search, the Delphi exercise was initiated. At the start, 153 (partly overlapping) propositions were produced, and after 2 anonymous Delphi rounds 10 final propositions were agreed upon (table 3). Third, proposition-specific searches were done, resulting in 5089 potentially useful studies, of which 165 were included to provide (circumstantial) evidence for propositions (table 4). Recommendations 1. The adverse effects of glucocorticoid therapy should be considered and discussed with the patient before glucocorticoid
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