Endocrinology and Metabolism Clinics of North America
Review articleGlucocorticoid withdrawal schemes in chronic medical disorders: A systematic review
Section snippets
The problem of glucocorticoid withdrawal in chronic medical disorders
Clinicians have used glucocorticoids for more than 40 years. After Kendall and coworkers isolated cortisone in 1935, clinicians administered it to a woman with severe rheumatoid arthritis in 1948. Although the clinical improvement was dramatic, certain adverse effects soon became apparent [1]. Glucocorticoids are used as replacement therapy in Addison's disease, in which therapy is lifelong and withdrawal is not possible. Clinicians use these agents for the treatment of inflammatory and
Types of studies
We included randomized controlled trials including data about the safety and efficacy of glucocorticoid withdrawal schemes.
Types of participants
We studied patients with any chronic medical disorder—a disorder which is permanent, leaves residual disability, is caused by an irreversible pathologic alteration, requires special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care.
Types of interventions
We were interested in comparisons of different forms of
Description of studies
The initial electronic search strategy resulted in 874 (possible randomized controlled or controlled clinical trials) references and 152 review articles.
After scanning these studies we identified 19 potential randomized controlled trials [13], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33] and nine Cochrane reviews [12], [34], [35], [36], [37], [38], [39], [40], [41] that appeared to fulfill the inclusion criteria. Inter-observer
Discussion
We were surprised to find only a few trials addressing the safety and efficacy of glucocorticoid withdrawal schedules in chronic diseases, because these agents are widely used in clinical practice. Theoretically, this could be the consequence of a too-narrow search strategy. We used a sensitive search strategy that had a basic set of key terms we hoped to find in a publication for further scrutiny. In addition, we examined all references of included and excluded studies. Moreover, we used the
Summary
This systematic review highlights the uncertainty about the safety and efficacy of glucocorticoid withdrawal in many chronic diseases, elucidating the need for further research in this area. The problem of glucocorticoid withdrawal seems to be a good example for wide variation in physicians' approaches to weaning patients off glucocorticoids. This practice variation appears justified, given the well known extraordinary array of individual reactions to systemic glucocorticoid therapy [44], the
Acknowledgements
We thank Karla Bergerhoff, Trials Search Coordinator of the Cochrane Metabolic and Endocrine Disorders Group, for establishment and execution of the search strategy.
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