Standardised nomenclature for glucocorticoid dosages and glucocorticoid treatment regimens: current questions and tentative answers in rheumatology

Abstract

In rheumatology and other medical specialties there is a discrepancy between the widespread use and the imprecise designation of glucocorticoid treatment regimens. Verbal descriptions of glucocorticoid treatment regimens used in various phases of diseases vary between countries and institutions. Given this background, a workshop under the auspices of the EULAR Standing Committee on International Clinical Studies including Therapeutic Trials was held to discuss this issue and to seek a consensus on nomenclature for glucocorticoid treatment. This report summarises the panel's discussion and recognises that answers derived from consensus conferences are not definitive. Nevertheless, recommendations on glucocorticoid treatment are presented that (1) reflect current and best knowledge available and (2) take into account current clinical practice. A question-answer rationale presentation style has been chosen to convey the messages, to summarise the meeting in a readable format, and to avoid dogmatism.

Figure 1

Relative potencies of various glucocorticoids to produce genomic and non-specific non-genomic effects. The figure shows a comparison between genomic and non-genomic potencies of various glucocorticoids. (A) Data for classic (genomic) effects were taken from Goodman and Gilman⁶ and are relative to cortisol. (B) Data for non-specific non-genomic effects were taken from Schmid et al⁸ and are relative to prednisolone. The value for prednisolone was set to 4 and values for the other glucocorticoids were scaled accordingly to allow direct comparison with the classic potencies. It should be noted that non-specific non-genomic effects are especially relevant in higher doses.

Figure 2

Current view on the dose dependency of genomic and non-genomic effects providing arguments for the description of glucocorticoid dosages. Figure 2 summarises the current knowledge on the occurrence of genomic and non-genomic effects in terms of a dose-response relationship.^1,2,6–10 This provided the basis for our recommendations on how to describe glucocorticoid doses; however, arguments concerning clinical feasibility have been taken into account. Against this background we stress that neither for genomic nor for non-genomic effects is there an exact knowledge of the relationship between dosage, concentration, and cellular and clinical effects (see text). However, this figure represents the result of our interpretation of currently available information on basic research results and clinical practice.