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    EULAR recommendations on steroids: ‘As necessary, but as little as possible’ | MDedge Rheumatology

    Item availability may be restricted. Article Networks TrendTerms. Patient age, childbearing potential, prevailing disease manifestations, safety concerns, and cost are factors that should inform the choice of immunosuppressive agent including methotrexate, azathioprine, and mycophenolate mofetil. Methotrexate and azathioprine should be considered in patients with poor symptom control after receiving glucocorticoids and hydroxychloroquine or when hydroxychloroquine alone is unlikely to be sufficient.

    Clarifying the role of steroids in rheumatoid arthritis

    Belimumab should be considered as an add-on therapy for patients with extrarenal disease who experience persistent disease activity or frequent flares. Currently, rituximab is only recommended in patients with severe refractory disease and it should only be considered in patients when more than 1 immunosuppressant agent has failed.

    First-line treatments of skin disease recommended for patients with SLE include topical agents glucocorticoids, calcineurin inhibitors , antimalarials hydroxychloroquine, quinacrine , and systemic glucocorticoids.


    In patients who do not respond to first-line treatments or who require high-dose glucocorticoids, methotrexate, retinoids, dapsone, or mycophenolate may be considered as add-on therapy. SLE-related neuropsychiatric manifestations, as opposed to non-SLE-related neuropsychiatric disorders, should be evaluated using neuroimaging techniques, testing cerebrospinal fluid, and assessing risk factors onset disease manifestations, patient age, non-neurological SLE activity, presence of antiphospholipid antibodies to exclude confounding.

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    • Recommended treatments include glucocorticoids and immunosuppressive agents if the manifestations reflect an inflammatory process or anticoagulants for antiphospholipid-related manifestations. Treatment of thrombocytopenia in SLE requires acute management of disease activity with high-dose glucocorticoid therapy including intravenous methylprednisolone or intravenous immunoglobulin G treatments. Beyond the acute stage, immunosuppressive-sparing or glucocorticoid-sparing agents such as mycophenolate, azathioprine, and cyclosporine may be used for maintenance therapy.

      Update of EULAR recommendations for the treatment of systemic sclerosis

      Rituximab or cyclophosphamide are only recommended in severe refractory cases. Early recognition and diagnosis of renal disease in SLE is essential for managing outcomes. Clinicians should perform a biopsy if renal involvement is suspected.

      Recommendations on Glucocorticoids for Rheumatic Diseases

      Higher doses may be considered for patients at high risk for renal failure. Mycophenolate and azathioprine should be used in ongoing maintenance therapy.

      Update of EULAR recommendations for the treatment of systemic sclerosis.

      Secondary prevention should apply the same therapeutic approach for primary antiphospholipid syndrome. Patients with SLE should be assessed for risk factors related to infection, including advanced age, diabetes mellitus, renal involvement, use of immunosuppressive agents or biologics, or glucocorticoid use.

      General preventative measures are recommended, such as immunizations, as is the early recognition and treatment of infection.