This is the patient version of the EULAR recommendations for the management of glucocorticoid medicines in people with rheumatic diseases. The original publication can be downloaded from the EULAR website: www.eular.org.

INTRODUCTION
Glucocorticoids (prednisone or prednisolone) are medicines to reduce inflammation. They are used in rheumatic diseases such as rheumatoid arthritis, polymyalgia, lupus and vasculitis for a long time. Documents called recommendations give advice to doctors and patients about the best way to treat and manage diseases. EULAR has written recommendations on glucocorticoids for people with rheumatic diseases before. Those recommendations focused on low (small) doses (less than 7.5 mg every day) rather than the medium or high (large) doses that some people need to take – sometimes as much as 100 mg every day. These new recommendations will make sure that higher doses are used safely. The recommendations were written by doctors and patients. The authors looked at the evidence on the use of medium and high doses of glucocorticoids. They looked especially at the adverse events (side effects) that the medicine can cause.

WHAT DO WE ALREADY KNOW?
Glucocorticoids reduce inflammation and stop damage that your disease might cause in your joints. These medicines also cause side effects. Increasing the dose increases the likelihood of side effects.

WHAT DO THE RECOMMENDATIONS SAY?
A lot of the recommendations talk about a balance between benefits and risks. This means whether the positive results from taking the medicine are more important than the negative things that might happen to you such as side effects and inconvenience. Each recommendation is based on available scientific evidence or proof. The more stars a recommendation has the stronger (more) the evidence is and the more important it is that you and your doctor follow it.

One star (*) means it is a weak recommendation with limited evidence.
Two stars (**) means it is a weak recommendation with some evidence.
Three stars (***) means it is a strong recommendation with some evidence.
Four stars (****) means it is a strong recommendation with a lot of evidence.

The recommendations are in three groups:
1) Education about how to stop side effects from happening
2) Information about how much medicine you need
3) What monitoring you need when you are taking this medicine

1. EDUCATION ABOUT HOW TO STOP SIDE EFFECTS FROM HAPPENING

• Your doctor should explain to you (and your family or carers) why you need medium or high doses of glucocorticoids, and what the risks are.**
  This will make sure that you understand how your medicine works and how it makes you feel better. If you are informed about your medicine you are more likely to take it properly.
• Talk to your doctor about ways you can reduce or prevent side effects. Your doctor may suggest that you change your diet and take regular exercise or tell you how to take care of any wounds (cuts or injuries) that you may get.*
  Look at your diet and increase how much calcium you get by including dairy products and green leafy vegetables. Stop smoking and limit how much alcohol you drink because this will be very positive for your bone and heart health. Staying active can help to keep bones and muscles strong and healthy. Glucocorticoids can stop injuries from healing normally. It is important to be aware of this and to take good care of any cuts or wounds you get.
• Your doctor will probably prescribe something to reduce the risk of osteoporosis (fragile bones) caused or made worse by your glucocorticoid treatment.****
  Glucocorticoids can reduce your bone density and you can be more likely to get fractures. Your doctor might give you calcium, vitamin D or bisphosphonates to help stop this happening.
• Your doctor should give you advice about how to manage suppression of the hypothalamic-pituitary-adrenal axis. This is when the glucocorticoids interfere with the normal relationship between these three glands in your body.*
  Some glands in the body naturally make steroids, and glucocorticoids can interfere with the normal balance. It is very important that you do not stop taking your medicine suddenly, as this can cause the glands to stop working properly.
• Your doctor should give you information on the best way to use your medicine.* This might be as printed booklets, or links to online help and advice.

2. INFORMATION ABOUT HOW MUCH MEDICINE YOU NEED

• Your doctor should work out if you have any comorbidities (other diseases). If you have one or more other diseases you will need to be looked after very carefully.*
  Some other diseases increase the chance of getting side effects. Make sure your doctor knows if you have diabetes, glucose intolerance, cardiovascular (heart) disease, peptic ulcer disease, recurrent or repeated infections, a weakened immune system, osteoporosis or glaucoma (a build-up of pressure and fluid in the eye).
• When you are first prescribed glucocorticoids, your doctor should choose the lowest dose needed to reduce your inflammation and make you feel better.* But it is important that your dose is not too low as this may not give you any benefit.**** Starting doses will be different for different people. This will depend on age, weight and the disease being treated. It might be better to start on a low dose and to gradually increase it if needed. Side effects are more likely with larger doses.
• Your medicine should be reviewed often because you might not need to keep taking glucocorticoids. Your dose might be changed depending on whether you are getting better or not and whether you have any side effects.****
  Regular check-ups are needed to make sure that the medicine is still right for you, and that the dose is correct.

3. WHAT MONITORING YOU NEED WHEN YOU ARE TAKING THIS MEDICINE

• You should be monitored for side effects.****
  You and your doctor should look out for signs of diabetes, hypertension (high blood pressure) and weight gain. You also need to let your doctor know if you have any infections, fractures, muscle weakness or pain in your joints that increases over time and is bad even when resting. Eye and skin problems and being confused or having memory loss can also be side effects of this medicine, so you should let your doctor know if any of these things happen.

Overall, the recommendations say that it is important for you and your doctor to work together to get the best possible results from treatment. If you have a rheumatic disease and are taking or have been offered glucocorticoids, these recommendations will give you tips about what you and your doctor need to do to give you the biggest benefit with the smallest risk of side effects.

It is important that you know why you are taking this medicine and are clear on which side effects you need to watch out for. You may be able to minimise some side effects by changing your lifestyle, such as being more physically active or changing your diet. Make sure your doctor knows if you suffer from any other diseases as these may be affected by glucocorticoids.

If you have any questions or concerns about your disease or your medication, you should speak to your doctor.

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Summary based on research article published on: 19 July 2013

From: Duru N, et al. EULAR evidence-based and consensus-based recommendations on the management of
medium to high-dose glucocorticoid therapy in rheumatic diseases. Ann Rheum Dis 2013;72(12):1905-13.
doi:10.1136/annrheumdis-2013-203249

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