Glucocorticoids (GCs) play a central role in the treatment of active systemic lupus erythematosus (SLE). Long-term GC-related side effects (i.e., infections, diabetes mellitus, cataract, osteoporosis, gastrointestinal bleeding and cardiovascular disease), leading to the development of irreversible organ damage, mean that clinicians must develop strategies for minimizing GC exposure in SLE.¹ Initiation of oral GC should be avoided, especially when there are effective therapeutic alternatives as for cutaneous and articular manifestations. In patients with lupus nephritis, starting GC with a medium prednisone dose (0.5 mg/kg/day) is as effective as high-dose dose (1 mg/kg/day) prednisone.¹ Use of intravenous methylprednisolone (MP) pulses (usually 250–1000 mg/day for 3 days) may allow for a lower starting dose and faster tapering of oral GC.^{2 3} Early initiation of immunosuppressive drugs can facilitate a more rapid GC tapering and may prevent SLE flares.⁴ Long-term GC administration with doses of ≤5 mg/day prednisone produces an acceptably low level of harm, with the exception of patients at high cardiovascular risk who may require preventive measures.⁵ Withdrawal of low dose prednisone is also recommended by EULAR, when possible,¹ but recent data suggest that this exposes SLE patients to an increased risk of flare, whereas its long-term maintenance is not associated with increased damage scores.⁶

Learning Objectives

• Describe strategies for minimizing corticosteroid dose at treatment initiation for lupus nephritis, cutaneous lupus and lupus arthritis

• Describe strategies for minimizing corticosteroid exposure when SLE remission has been reached

References

1. Fanouriakis A, Kostopoulou M, Alunno A, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–45.

2. Ruiz-Arruza I, Lozano J, Cabezas-Rodriguez I, et al. Restrictive Use of Oral Glucocorticoids in Systemic Lupus Erythematosus and Prevention of Damage Without Worsening Long-Term Disease Control: An Observational Study. Arthritis Care Res (Hoboken). 2018;70(4):582–91.

3. Ruiz-Irastorza G, Petri M, Gordon C, Khamashta M. Managing lupus nephritis in pregnant women: comment on the article by Hahn, et al. Arthritis Care Res (Hoboken). 2013;65(8):1391–2.

4. Pego-Reigosa JM, Cobo-Ibanez T, Calvo-Alen J, et al. Efficacy and safety of nonbiologic immunosuppressants in the treatment of nonrenal systemic lupus erythematosus: a systematic review. Arthritis Care Res (Hoboken). 2013;65(11):1775–85.

5. Strehl C, Bijlsma JW, de Wit M, et al. Defining conditions where long-term glucocorticoid treatment has an acceptably low level of harm to facilitate implementation of existing recommendations: viewpoints from an EULAR task force. Ann Rheum Dis. 2016;75(6):952–7.

6. Mathian A, Pha M, Haroche J, et al. Withdrawal of low-dose prednisone in SLE patients with a clinically quiescent disease for more than 1 year: a randomised clinical trial. Ann Rheum Dis. 2020;79(3):339–46.