EULAR evidence based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVES: To develop evidence based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases. METHODS: The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologistepidemiologist, 1 health professional, 1 patient and 1 research fellow. Each participant contributed up to 10 propositions describing key clinical points concerning the use of GCs. The final recommendations were agreed using a Delphi consensus approach. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was used to identify the best available research evidence to support each of the 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 (AEs), concomitant therapy (i.e. non-steroidal antiinflammatory drugs (NSAIDs), gastroprotection and cyclo-oxygenase-2 selective inhibitors (coxibs), calcium and vitamin D, bisphosphonates), and special safety advice (i.e. adrenal insufficiency, pregnancy, growth impairment). Of the 10 propositions, only 3 propositions were fully supported and 2 were partially supported by research evidence. The remaining propositions were supported by circumstantial evidence and/or by expert opinion alone. The strength of each recommendation differed according to level of evidence and clinical expertise. CONCLUSION: Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. For all propositions the evidence was evaluated and the strength of recommendation was provided. There are areas of importance that have little evidence (i.e. dosing and tapering strategies, timing, risk factors and AE-monitoring, perioperative GC-replacement) and need further research; therefore also a research agenda was formulated.