title: Defining conditions where long-term glucocorticoid treatment has an acceptably low level of harm to facilitate implementation of existing recommendations: viewpoints from an EULAR task force.
abstract: There is convincing evidence for the known and unambiguously accepted beneficial effects of glucocorticoids at low dosages. However, the implementation of existing recommendations and guidelines on the management of glucocorticoid therapy in rheumatic diseases is lagging behind. As a first step to improve implementation, we aimed at defining conditions under which long-term glucocorticoid therapy may have an acceptably low level of harm. A multidisciplinary European League Against Rheumatism task force group of experts including patients with rheumatic diseases was assembled. After a systematic literature search, breakout groups critically reviewed the evidence on the four most worrisome adverse effects of glucocorticoid therapy (osteoporosis, hyperglycaemia/diabetes mellitus, cardiovascular diseases and infections) and presented their results to the other group members following a structured questionnaire for final discussion and consensus finding. Robust evidence on the risk of harm of long-term glucocorticoid therapy was often lacking since relevant study results were often either missing, contradictory or carried a high risk of bias. The group agreed that the risk of harm is low for the majority of patients at long-term dosages of ≤5 mg prednisone equivalent per day, whereas at dosages of >10 mg/day the risk of harm is elevated. At dosages between >5 and ≤10 mg/day, patient-specific characteristics (protective and risk factors) determine the risk of harm. The level of harm of glucocorticoids depends on both dose and patient-specific parameters. General and glucocorticoid-associated risk factors and protective factors such as a healthy lifestyle should be taken into account when evaluating the actual and future risk.
authors.affiliation: Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin, Germany.
authors.forename: Cindy
authors.initials: C
authors.lastname: Strehl
authors.affiliation: Department of Rheumatology and Clinical Immunology, University Medical Centre Utrecht, Utrecht, the Netherlands Amsterdam Rheumatology& Immunology Center, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Johannes W J
authors.initials: JW
authors.lastname: Bijlsma
authors.affiliation: Medical Humanities, VU Medical Centre, Amsterdam, the Netherlands.
authors.forename: Maarten
authors.initials: M
authors.lastname: de Wit
authors.affiliation: Amsterdam Rheumatology& Immunology Center, VU University Medical Center, Amsterdam, the Netherlands Department of Epidemiology & Biostatistics, VU University Medical Center, Amsterdam, the Netherlands.
authors.forename: Maarten
authors.initials: M
authors.lastname: Boers
authors.affiliation: Patient Research Partner, Mol, Belgium.
authors.forename: Nele
authors.initials: N
authors.lastname: Caeyers
authors.affiliation: Department of Internal Medicine, Research Laboratory & Academic Division of Clinical Rheumatology, University of Genoa, Genova, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Cutolo
authors.affiliation: Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, Essex, UK.
authors.forename: Bhaskar
authors.initials: B
authors.lastname: Dasgupta
authors.affiliation: Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester, UK.
authors.forename: William G
authors.identifier: 0000-0001-5881-4857
authors.initials: WG
authors.lastname: Dixon
authors.affiliation: Department of Clinical & Health Psychology, Utrecht University, Utrecht, the Netherlands.
authors.forename: Rinie
authors.initials: R
authors.lastname: Geenen
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Tom W J
authors.initials: TW
authors.lastname: Huizinga
authors.affiliation: Salisbury Foundation Trust NHS Hospital, Wiltshire, UK.
authors.forename: Alison
authors.initials: A
authors.lastname: Kent
authors.affiliation: Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.
authors.forename: Annette Ladefoged
authors.initials: AL
authors.lastname: de Thurah
authors.affiliation: Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Listing
authors.affiliation: Department of Rheumatology, Assistance Publique-Hopitaux de Paris, Hôpitaux Universitaires Paris-Sud, Le Kremlin Bicêtre, France Université Paris-Sud; INSERM U1184, Le Kremlin Bicêtre, France.
authors.forename: Xavier
authors.initials: X
authors.lastname: Mariette
authors.affiliation: Faculty of Medical and Health Sciences, University of Manchester, Manchester, UK.
authors.forename: David W
authors.initials: DW
authors.lastname: Ray
authors.affiliation: Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands.
authors.forename: Hans U
authors.initials: HU
authors.lastname: Scherer
authors.affiliation: Department of Rheumatology, Assistance Publique-Hopitaux de Paris, Hôpitaux Universitaires Paris-Sud, Le Kremlin Bicêtre, France Université Paris-Sud; INSERM U1184, Le Kremlin Bicêtre, France.
authors.forename: Raphaèle
authors.initials: R
authors.lastname: Seror
authors.affiliation: Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin, Germany.
authors.forename: Cornelia M
authors.initials: CM
authors.lastname: Spies
authors.affiliation: Department of Rheumatology, The Parker Institute, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Denmark.
authors.forename: Simon
authors.initials: S
authors.lastname: Tarp
authors.affiliation: Deutsche Reuma-Liga, Bonn, Germany.
authors.forename: Dieter
authors.initials: D
authors.lastname: Wiek
authors.affiliation: Divisions of Infectious Diseases, Oregon Health & Science University, Portland, USA.
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Winthrop
authors.affiliation: Department of Rheumatology and Clinical Immunology, Charité University Medicine, Berlin, Germany.
authors.forename: Frank
authors.initials: F
authors.lastname: Buttgereit
mesh_terms: D026683:Advisory Committees; D032921:Consensus; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D064420:Drug-Related Side Effects and Adverse Reactions / Q000209:etiology*; D005938:Glucocorticoids / Q000008:administration & dosage* / Q000009:adverse effects*; D006801:Humans; D008134:Long-Term Care / Q000379:methods*; D012216:Rheumatic Diseases / Q000188:drug therapy*; D012307:Risk Factors; D013997:Time Factors
chemical_list: D005938:Glucocorticoids
keywords: Cardiovascular Disease; Corticosteroids; Infections; Osteoporosis; Rheumatoid Arthritis