UTRECHT, The Netherlands—A European Union League Against Rheumatism (EULAR) task force on glucocorticoids (GCs), which included a patient, has just published 10 key recommendations for the management of systemic GC therapy in rheumatic diseases.¹ The evidence-based guidelines are notable for close attention to monitoring and management of GC-related adverse events (AEs) and for laying out a clear research agenda that identifies current gaps in knowledge.

Lead author J. N. Hoes, MD, from the department of rheumatology and clinical immunology at University Medical Center in Utrecht, The Netherlands, writes, "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."

The panel that developed the guidelines included 15 rheumatologists and one of each of the following: internist, rheumatologist-epidemiologist, health professional, patient, and research fellow. They used the Delphi method to agree on 10 key propositions, and then conducted a systematic literature search to identify the best available research evidence to support each proposition. Recommendations were identified according to their strengths, which were based on research evidence, clinical expertise, and perceived patient preference.

10 recommendations for better use of glucocorticoids in rheumatic diseases

The EULAR recommendations were as follows:
1. GC AEs should be considered and discussed with the patient before starting therapy, and this should be reinforced by giving information about GC management and by issuing a "GC card" to every patient who will be on long-term therapy, noting the date treatment began, the initial dosage, and the subsequent dose reductions and maintenance regimens.
2. Initial dose, dose reduction, and long-term dosing depend on the underlying disease activity, risk factors, and individual responsiveness of the patient. Circadian rhythm timing may influence both the diseased and the natural secretion of GCs.
3. When starting GCs, evaluate and treat comorbidities and risk factor for AEs, including hypertension; diabetes; peptic ulcer; recent fractures; presence of cataract, glaucoma, or chronic infections; dyslipidemia; and use of NSAIDs.
4. Keep GC dosage to a minimum for long-term treatment and attempt to taper in case of remission or low disease activity.
5. Monitor patients for body weight, blood and ocular pressure, peripheral edema, cardiac insufficiency, serum lipids, blood and/or urine glucose.
6. Prescribe calcium and vitamin D supplementation for the patient who is started on prednisone >e;7.5 mg daily and continued on prednisone for >3 months.
7. Prescribe gastroprotection such as proton pump inhibitors for patients taking GCs and concomitant NSAIDs, or switch to a coxib.
8. Patients on GC therapy for >1 month who will have surgery should have perioperative management with adequate GC replacement to overcome potential adrenal insufficiency.
9. GCs during pregnancy carry no additional risk for either mother or child.
10. Monitor linear growth regularly in children taking GCs and consider growth hormone replacement in case of growth impairment.

...but major knowledge gaps remain

In the course of compiling these recommendations, the panel also pinpointed major gaps in knowledge. The resulting "research agenda" includes the need for studies of how patients, general physicians, and rheumatologists perceive the safety and management of GCs in rheumatic disease; the effect of low-dose GCs on lipid profile and cardiovascular risk factors; the pathophysiology of GC-associated skin side effects; the optimal timing for GC therapy; and whether, in early rheumatoid arthritis, a continuous low dose of GCs is as effective as step-down dosing.

Dr. Hoes said that a major clinical lacking is the absence of a standardized scoring system for GC-related AEs, which makes monitoring them in clinical trials difficult. The panel also asked for studies of biomarkers that might predict GC toxicity, and of strategies for predicting and preventing GC-associated cataract and glaucoma.

Finally, the EULAR panel would like studies to determine whether GCs also inhibit radiographic progression in patients with longstanding rheumatoid arthritis, the pathophysiological mechanism that causes steroid myopathy, and the genomic and nongenomic mechanisms of GC actions and side effects.

Factors to be Monitored in Patients Taking Systemic Glucocorticoids

• Body weight
• Blood pressure
• Peripheral edema
• Cardiac insufficiency
• Serum lipids
• Blood and/or urine glucose
• Ocular pressure

Adapted from Ann Rheum Dis. 2007;66:1560-1567.¹


Adverse Events That Should be Monitored in Rheumatology Patients Taking Systemic Glucocorticoids

• Hypertension
• Diabetes
• Osteoporosis
• Gastric ulcer
• Cataract
• Glaucoma
• Infections
• Dyslipidemia

Adapted from Ann Rheum Dis. 2007;66:1560-1567.¹

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