Table 3 Experts' propositions developed throughout 3 Delphi rounds including the strength of recommendation.
| Proposition | SOR | Evidence level of data | ||
|---|---|---|---|---|
| VAS 100 (95% CI) | A+B % | |||
| 1 a | The adverse effects of glucocorticoid therapy should be considered and discussed with the patient before glucocorticoid therapy is started | 92 (85 to 100) | 93 | IV |
| 1 b | This advice should be reinforced by giving information regarding glucocorticoid management | 88 (80 to 96) | 93 | IV |
| 1 c | If glucocorticoids are to be used for a more prolonged period of time, a “glucocorticoid card” is to be issued to every patient, with the date of commencement of treatment, the initial dosage and the subsequent reductions and maintenance regimens | 78 (67 to 89) | 79 | IV |
| 1 | Full proposition (1A+1B+1C) | 91 (86 to 96) | 92 | |
| 2 a | Initial dose, dose reduction and long‐term dosing depend on the underlying rheumatic disease, disease activity, risk factors and individual responsiveness of the patient | 92 (83 to 100) | 86 | IA–III |
| 2 b | Timing may be important, with respect to the circadian rhythm of both the disease and the natural secretion of glucocorticoids | 74 (59 to 89) | 57 | – |
| 2 | Full proposition (2A+2B) | 83 (70 to 97) | 85 | |
| 3 | When it is decided to start glucocorticoid treatment, comorbidities and risk factors for adverse effects should be evaluated and treated where indicated; these include hypertension, diabetes, peptic ulcer, recent fractures, presence of cataract or glaucoma, presence of (chronic) infections, dyslipidaemia and comedication with non‐steroidal anti‐inflammatory drugs | 92 (87 to 96) | 100 | IV |
| 4 | For prolonged treatment, the glucocorticoid dosage should be kept to a minimum, and a glucocorticoid taper should be attempted in case of remission or low disease activity; the reasons to continue glucocorticoid therapy should be regularly checked | 81 (68 to 94) | 86 | IV |
| 5 | During treatment, patients should be monitored for body weight, blood pressure, peripheral oedema, cardiac insufficiency, serum lipids, blood and/or urine glucose and ocular pressure depending on individual patient's risk, glucocorticoid dose and duration | 89 (81 to 97) | 93 | IV |
| 6a | If a patient is started on prednisone ⩾7.5 mg daily and continues on prednisone for more than 3 months, calcium and vitamin D supplementation should be prescribed | 95 (91 to 99) | 100 | IA |
| 6b | Antiresorptive therapy with bisphosphonates to reduce the risk of glucocorticoid‐induced osteoporosis should be based on risk factors, including bone‐mineral density measurement | 96 (92 to 99) | 93 | IB–III |
| 6 | Full proposition (6A+6B) | 95 (89 to 100) | 100 | |
| 7 | Patients treated with glucocorticoids and concomitant non‐steroidal anti‐inflammatory drugs should be given appropriate gastro‐protective medication, such as proton pump inhibitors or misoprostol, or alternatively could switch to a cyclo‐oxygenase‐2 selective inhibitor | 91 (84 to 98) | 93 | 1A–IB |
| 8 | All patients on glucocorticoid therapy for longer than 1 month, who will undergo surgery, need perioperative management with adequate glucocorticoid replacement to overcome potential adrenal insufficiency | 91 (84 to 99) | 93 | IV |
| 9 | Glucocorticoids during pregnancy have no additional risk for mother and child | 87 (78 to 96) | 86 | IB–III |
| 10 | Children receiving glucocorticoids should be checked regularly for linear growth and considered for growth‐hormone replacement in case of growth impairment | 93 (85 to 100) | 93 | IB |
*A+B%, percentage of the taskforce members that strongly to fully recommended this proposition, based on an A–E ordinal scale; CI, confidence interval; SOR, strength of recommendation; VAS, visual analogue scale (0–100 mm, 0 = not recommended at all, 100 = fully recommended).