Steroid use provided by the standardized steroid regimen (SSR)
| INITIAL 4 WEEKS OF INDUCTION THERAPY | |||
|---|---|---|---|
| PO CS | IV CS | ||
| Patients ≥ 50 kg | Prednisone* 60 mg/day divided in up to 4 doses | Up to 3 doses (30 mg/kg; max 1 gram of methylprednisolone) | |
| Patients < 50 kg | Prednisone 1.5 mg/kg/day | ||
| Median – lowest PO CS dose at week 4** | 40 mg/day - 30 mg/day | ||
| WEEK 5 – 26 OF INDUCTION THERAPY (based on LN and ER trends since last visit) | |||
|
LN course
(assumption ER is stable) | Much worse | Increase PO CS to 50-60mg/day; re-assess in 1-3 weeks; if response to increased PO CS is (a) Satisfactory→ No IV CS; (b) non-satisfactory→ IV
pulses + PO CS;
Possible change of immunosuppressive drug | |
| Mild – moderately worse | Increase PO CS by about 30% (if dose < 40 mg; max 60 mg) | ||
| Active stable | Stable PO CS dose (if dose < 40 mg; else: slow decrease) | ||
| Improved active or PRR1 | Slow decrease of PO CS dose | ||
| CRR2 | More pronounced decrease of PO CS dose | ||
|
ER course
(assumption LN is stable) | Much worse | Increase PO CS dose; Re-assess in 1-3 weeks; if response to increased PO CS dose is (a) Satisfactory→ No IV CS; (b) non-satisfactory→ IV
pulses + PO CS dose;
Possible change of immunosuppressive drug | |
| Mild- moderately worse | Increase PO CS by 20% for doses < 40 mg; otherwise stable PO CS dose | ||
| Active stable or improved active | Stable PO CS dose | ||
| Inactive | Decrease PO CS dose | ||
| Median - Lowest PO CS dose possible at week 26 | 12.5 - 10 mg/day | ||
| BEYOND 26 WEEKS POST KIDNEY BIOPSY - MAINTENANCE THERAPY | |||
|
LN course
(assumption ER is stable) | Flare3 after PRR/CRR | Prednisone ≥ 40 mg, irrespective of ER course Re-assess in 1-3 weeks; if response to increased PO CS is (a) Satisfactory→ No IV CS; (b) non-satisfactory→ IV pulses + PO CS | |
| Worse after PRR/CRR | Increase the PO CS dose FIRST | ||
| PRR stable | Slow decrease of the SSR-dose | ||
| Inactive/CRR or PRR improved | More pronounced decrease of the SSR dose | ||
| ER course (assumption PRR parameters are stable) | Much worse | Increase PO CS dose by 30-50% (max 60 mg) ; Re-assess in 1-3 weeks; if response to increased PO CS dose is (a) Satisfactory→ No IV CS ; (b) non-satisfactory→ IV
pulses + PO CS;
Possible change of immunosuppressive drug | |
| Mild- moderately worse | Increase PO CS dose by 25% for doses < 40 mg; otherwise stable PO CS dose | ||
| Stable/Improved/Inactive | Decrease of the PO CS dose | ||
** For patients ≥ 50 kg; * or corticosteroid equivalent dose.
1 Partial renal remission (PRR): >50% improvement of ≥2 LN-RVs PLUS remaining LN-RV is NOT worse.
2 Complete renal remission (CRR): All LN-RVs are NORMAL.
3 LN flare defined by at least 1 of the LN-RV changes being persistently present on ≥2 subsequent time points ≥1week apart. LN-RV changes are defined as (a) newly abnormal GFR, (b) abnormal GFR that decreased by >10%, (c) persistent increase of UPCR to ≥0.5, after CRR, (d) persistent doubling of UPCR with values ≥1.0, after PRR, or (e) newly active or worsening glomerular hematuria.