Indications of glucocorticoids in early arthritis and rheumatoid arthritis: recommendations for clinical practice based on data from the literature and expert opinion.

Objective: To develop clinical practice guidelines about the indications of glucocorticoid therapy in early arthritis and established rheumatoid arthritis, based on previously published data and on the opinions of rheumatology experts.

Methods: We used a three-step procedure. (a) A scientific committee used a Delphi procedure to select three questions about glucocorticoid indications: what is the role for glucocorticoid therapy in early arthritis? What is the role for long-term glucocorticoid therapy in established rheumatoid arthritis? What is the role for systemic glucocorticoid therapy in flares of rheumatoid arthritis? (b) Evidence providing answers to the three questions was sought in Pubmed, Embase, Cochrane, and abstracts from the annual meetings of the ACR and EULAR. (c) Based on this evidence, recommendations were developed and validated by a panel of experts. The strength of each recommendation was determined based on the level of the underlying evidence. The level of agreement among experts regarding each recommendation was measured.

Results: The literature search retrieved 2851 publications, of which 36 were selected based on the titles and abstracts then on the full-length articles. These 36 studies were presented to the experts as a basis for discussion. Six recommendations rated A to D were developed and validated by the experts. They dealt with the appropriateness of low- or moderate-dose glucocorticoid therapy for a limited period in early polyarthritis after advice from a specialist and in the event of active disease, in combination with disease-modifying antirheumatic drug (DMARD) therapy; the appropriateness of low-dose glucocorticoid therapy (no more than 0.1mg/kg/day) in RA if needed to achieve symptom control; and the appropriateness of oral glucocorticoid therapy (no more than 0.5mg/kg/day) for 1 to 2 weeks in polyarticular flares of RA.

Conclusion: The six recommendations for everyday practice presented here should help to standardize and to optimize clinical practice, thereby improving the management of patients with early arthritis or RA.