Pulse doses of glucocorticoids (e.g., 500 mg of intravenous methylprednisolone) are commonly used to treat SLE flares. “We can get maximal anti-inflammatory effects from the genomic and nongenomic pathway by giving these high doses for a short period of time. [And by only using high doses as a short pulse], there’s less time for the toxic genomic effects of glucocorticoids to appear,” Dr. Ruiz-Irastorza said.
Tip of the Iceberg
Most of us are familiar with the SLE iceberg analogy, which depicts disease activity as the tip of the iceberg and damage as the mass of ice below the surface. Studies confirm that damage doesn’t come from active SLE alone; glucocorticoid exposure contributes as well.3
In addition, damage as measured by clinical trial damage indices isn’t the only consequence of glucocorticoids. Cosmetic side effects, such as abdominal striae, are also distressing to patients. “These must be taken into consideration since they can result in a high impact on quality of life,” Dr. Ruiz-Irastorza noted.
Can We Use Less?
And now, the million-dollar question: Can we use less glucocorticoids to care for our SLE patients? “There’s growing evidence that lower doses of prednisone work well, especially in lupus nephritis,” said Dr. RuizIrastorza. “Studies show we may even be able to stop glucocorticoids completely in some patients; however, about 20% of these patients will flare, and half of those flares will be severe.”4
The 2019 EULAR recommendations for the management of SLE state that “during chronic maintenance treatment, glucocorticoids should be minimized to less than 7.5 mg per day (prednisone equivalent) and, when possible, withdrawn.”5 However, neither EULAR nor ACR guidelines provide specific instructions on how to taper prednisone, and the use of high-dose oral prednisone (1 mg/kg/day) has become standard for treating moderate to severe lupus activity. Prednisone tapering schedules vary by institution.
“In the last 15 years in our unit,” said Dr. Ruiz-Irastorza, “we’ve been using a slightly different way of tapering glucocorticoids, which we’ve based on three basic principles of action.” These include:
- Hydroxychloroquine as the cornerstone of SLE treatment for all patients;
- Maintenance prednisone doses no greater than 5 mg daily; and
- Pulse doses of methylprednisolone in combination with immunosuppressives at first, with a transition to low-medium glucocorticoid doses that are quickly tapered.
“A patient who’s in ‘clinical remission’ on [maintenance] prednisone 10 mg daily is not actually in clinical remission. We must do whatever it takes to reduce this dose. Until then, we must not consider the patient in remission,” he explained.
