Background Glucocorticoids (GC) are a mainstay therapy for disease activity in Systemic lupus erythematosus (SLE) patients. In addition to induction of remission, many SLE patients receive long-term maintenance treatment with GC. On the reverse side, it is well established that GC use results in important adverse effects that are directly proportional to the dose and duration of GC treatment. These includes increased risk of infections and accrual of irreversible organ damage, that are major contributors to the morbidity and mortality of SLE patients. Hence, risk-benefit must be carefully considered for optimal use of GC and improve outcomes of SLE patients.

However, evidence base is still scarce for establishing standardized approaches to GC initiation, tapering and withdrawal for optimal management of SLE. As a result, clinical practice regarding use of GC in the treatment of SLE patients is wildly heterogenous.

Methods This review will focus on evidence and recommendations to optimize use of GC, which is a critical unmet need in the management of SLE.

Results Induction treatment of moderate and severe inflammatory lupus manifestations is the major indication for GC in SLE. In patients with milder manifestations, such as localized mucocutaneous lesions, arthralgias and mild cytopenia, hydroxychloroquine is the mainstay of treatment and use of systemic GC might not be needed. Common mild complaints, including arthralgia, myalgia, fatigue, headache or mild cognitive symptoms can be frequently due to non-inflammatory comorbidities, that must be differentiated from lupus flares and do not benefit from GC treatment. In treat-to-target strategy for SLE management, tapering of GC to ≤7.5 or preferably ≤5 mg/day of prednisone is an important objective, as it is associated with improved outcomes. Use of low dose prednisone in maintenance treatment of SLE patients is controversial. A recently published clinical trial showed that in SLE patients with quiescent disease, withdrawal of 5 mg/day of prednisone was associated with an increased risk of flare, however there was no significant difference in the risk of severe flares.

Conclusions Minimization of exposure to GC, along with achieving a stable remission or at least a low disease activity state are cent ral targets in the management of SLE. For this purpose, it is fundamental a judicious use of GC for treatment of disease activity, and to optimize use and adherence to hydroxychloroquine and immunosuppressant therapy in order to achieve successful tapering and whenever possible the withdrawal of GC.