The Great Pediatric Debate—Corticosteroids in SLE: Slay or Stay?

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CHICAGO—Corticosteroids have been an essential tool for the treatment of SLE since the 1950s. However, long-term use is associated with numerous adverse effects, particularly in children, and guidance is lacking on how to manage low-dose prednisone in clinically quiescent disease. In The Great Debate at ACR Convergence 2025—Corticosteroids in Pediatric SLE: Slay or Stay, two pediatric lupus experts took to the stage to explore this important topic.

An Opening Case

The presentation opened with a hypothetical case to frame the ensuing arguments. The patient was a 15-year-old girl with systemic lupus erythematosus (SLE) with class III/V lupus nephritis (LN) diagnosed three years prior. She had positive serologies including antiphospholipid antibodies. She required hemodialysis at diagnosis and treatment with IV corticosteroids, cyclophosphamide via the EuroLupus regimen and belimumab. She was continued on 7.5 mg daily oral prednisone, mycophenolate and belimumab. She’d had a SLEDAI 2K of less than 4 for the previous six months, with normal complements, negative anti-dsDNA antibodies, and a normal urine protein-creatinine ratio. With attempts to wean prednisone to 5 mg daily, complements declined.

Before the debate began, live polling of the audience demonstrated that a majority of the attendees would attempt to taper prednisone to 0 mg over the next six months.

In Favor of Discontinuing Corticosteroids

Dr. Emily von Scheven

Emily von Scheven, MD, MAS, professor of pediatrics and director of the Division of Pediatric Rheumatology at the University of California, San Francisco, was not subtle about her aversion to corticosteroids and their long-term consequences. She highlighted the multi-faceted impact that corticosteroids have on patients, leading to a lifetime of damage. Corticosteroids have been shown to be associated with poor body image, particularly due to their Cushingoid effects and visible changes on patients’ bodies.¹ Corticosteroids also result in osteoporosis and incident compression fractures in children, as well as stunted growth development and short stature.^2,3

From a cardiovascular perspective, patients with childhood-onset SLE have 100–300 times the risk of cardiovascular disease-related mortality, and 30% of pediatric lupus patients have subclinical atherosclerosis—both likely mediated and exacerbated by long-term exposure to corticosteroids.^4,5 At baseline, patients with pediatric SLE  are also at higher risk of infection, with even greater risk for those on corticosteroids.⁶

Dr. von Scheven pointed out that, unfortunately, a large number of patients do not attain a Lupus Low Disease Activity State (LLDAS), which by definition, requires a prednisone dose of less than or equal to 7.5 mg daily.⁷ Likewise, the definition of remission in SLE (DORIS) requires corticosteroids of no more than 5 mg/day for adults, with a similar proposed definition in children.⁸ However, she noted that achieving remission is indeed possible. In a cohort of 50 patients with pediatric SLE in Turkey, 66% of patients achieved the child DORIS definition of remission, and only complement levels, but not anti-dsDNA antibodies, were associated with continued disease activity and inability to achieve remission.⁹