The European League Against Rheumatism (EULAR) has issue guidelines for the management of glucocorticoid (steroid, cortisone) therapy in arthritis. EULAR is the equivalent of the American College of Rheumatology in the United States.
Approximately 20 leading experts on steroid therapy reviewed 5,089 studies to develop the final guidelines they recommended.
These include the following:
Adverse effects of steroid therapy (also known as glucocorticoid therapy), which usually is prednisone should be considered and discussed with the patient before starting steroid therapy.
All patients taking long term therapy should carry a card stating when the treatment was started, the initial dose, and subsequent changes in dose.
Dosing decisions should be based on the underlying disease, disease activity, risk factors, and individual patient responsiveness. The timing of the dose is important because of the body’s normal circadian rhythm and how this is affected by glucocorticoids.
Co-morbidities (other medical conditions) and risk factors for side effects such as diabetes and hypertension should be assessed and treated. Patients with these conditions need to be followed closely.
When treatment is prolonged, steroid dosages should be minimized and attempts should be made to taper the therapy when a patient goes into remission or their disease becomes relatively quiet.
Patients taking glucorticoids longer than one month who undergo surgery should receive adequate glucocorticoid replacement at the time of surgery to counteract adrenal insufficiency. Patients taking long-term steroids tend to have adrenal glands that act sluggishly and they don’t respond normally during periods of stress; hence, the need for replacement therapy.
Calcium and vitamin D should be prescribed for patients receiving more than 7.5 mgs prednisone a day for longer than three months.
Patients who take glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDS) at the same time should receive treatment to protect their stomach. Drugs such as proton pump inhibitors or misoprostol can be used or a patient could receive a COX-2 drug in place of the NSAID.
Glucocorticoid therapy during pregnancy seems to pose no additional risk to the mother or child. Children who receive glucocorticoids need to have their growth monitored and be considered for growth hormone replacement in their growth is impaired.
The bulk of these guidelines are already followed by most American rheumatologists. So while their standardization is welcomed, there is no jaw-opening news here.
One issue they didn’t discuss is cortisone shots. They should be given in a single joint no more often than three times a year to avoid side effects.