Toscana Medica - Novembre-Dicembre 2021

8/2021 T OSCANA M EDICA 32 testatina quali à e professione trattato in tutti i pazienti che fanno uso di steroidi ma soprattutto nei pazienti anziani o con storia di frat- ture spontanee. Nella Figura 3 possiamo vedere gli interventi che devono essere consi- derati. Importante è poi il decalage ste- roideo come rappresentato nella Figura 4. Anche la supplementazione con aci- del dolore ma anche effetti collate- rali come osteoporosi, mialgie, infe- zioni, ritenzione idrica, aumentati rischi cardiovascolari, ulcera gastri- ca, irsutismo ecc. Sul versante dell’osteoporosi e del rischio di fratture sappiamo che questa complicanza è presente an- che solo nella somministrazione di 2,5-7,5 mg/die di prednisone e que- sto effetto collaterale deve essere Possiamo vedere dunque come nel- la Tabella IV ( grade nel trattamen- to) venga data molta enfasi al tratta- mento steroideo e si sottolinea, cosa questa non sempre praticata dal curante, la necessaria prevenzione dell’osteoporosi nel trattamento steroideo. Sappiamo infatti che i glicocorticoi- di hanno effetti benefici sul versan- te flogistico, immunosoppressivo e Tabella III – Terapia: gradi di raccomandazione. Grade of Recommendation Clarity of risk/benefit Quality of supporting evidence Implications 1A. Strong recommendation, high quality evidence Benefits clearly outweigh risk and burdens, or vice versa. Consistent evidence from well performed randomized, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk. Strong recommendations, can apply to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. 1B. Strong recommendation, moderate quality evidence Benefits clearly outweigh risk and burdens, or vice versa. Evidence from randomized, controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other research design. Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate. Strong recommendation and applies to most patients. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. 1C. Strong recommendation, low quality evidence Benefits appear to outweigh risk and burdens, or vice versa. Evidence from observational studies, unsystematic clinical experience, or from randomized, controlled trials with serious flaws. Any estimate of effect is uncertain. Strong recommendation, and applies to most patients. Some of the evidence base supporting the recommendation is, however, of low quality. 2A. Weak recommendation, high quality evidence Benefits closely balanced with risks and burdens. Consistent evidence from well performed randomized, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk. Weak recommendation, best action may differ depending on circumstances or patients or societal values. 2B . Weak recommendation, moderate quality evidence Benefits closely balanced with risks and burdens, some uncertainly in the estimates of benefits, risks and burdens. Evidence from randomized, controlled trials with important limitations (inconsistent results, methodologic flaws, indirect or imprecise), or very strong evidence of some other research design. Further research (if performed) is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate. Weak recommendation, alternative approaches likely to be better for some patients under some circumstances. 2C. Weak recommendation, low quality evidence Uncertainty in the estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens. Evidence from observational studies, unsystematic clinical experience, or from randomized, controlled trials with serious flaws. Any estimate of effect is uncertain. Very weak recommendation; other alternatives may be equally reasonable. Anemia emolitica primaria da anticorpi caldi Raccomandazioni per il trattamento della CHAD primaria Prevenzione dell’osteoporosi Trattamento di prima linea con prednisolone 1 mg/kg/die Ai pazienti dovrebbe essere indicato di non esporsi al freddo quando possibile Indicazioni per il trattamento: anemia sintomatica, sintomi circolatori severi o trasfusione dipendenti Trattamento di prima linea con rituximab o, se è dimostrata la clonalità, si può valutare l’aggiunta di fludarabina A tutti i pazienti devono essere somministrati calcio orale e vitamina D nel corso del trattamento con corticosteroidi 1A 1C 1C 1B 1A Tabella IV – Grade nel trattamento.