ACR Convergence 2025| Video: Rheum for Everyone, Episode 26—Ableism

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

Michael Cammarata, MD, RhMSUS  |  

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.

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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

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

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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

Dr. von Scheven explained that 50–60% of damage accrual in SLE is due to corticosteroids, particularly in doses over 6–7 mg.10 She argued that the EULAR guidelines, which recommend steroid dose reduction and discontinuation when possible were in line with her position. She also highlighted a cohort of adult patients with SLE in Naples, demonstrating that corticosteroid discontinuation was feasible, with flare rates comparable to patients continued on corticosteroids.11

She advocated for the development of research protocols to guide corticosteroid tapering, analogous to the careful attention given to induction regimens. As an example, she shared the experience of the Toronto Lupus Clinic, which gradually discontinued prednisone over three months, and demonstrated reduced flare risk by 70%.12 However, Dr. Brunner later reviewed the same data, countering that these patients had already been in clinical remission for more than two years.

Dr. von Scheven clearly demonstrated the deleterious effects that corticosteroids have on children, and advocated for a rational approach to prednisone tapering, rather than one rooted in negativity bias and fear of flare.

Against Discontinuing Corticosteroids

The counterargument was presented by Hermine Brunner, MD, MSc, MBA, professor of pediatrics and director of the Division of Rheumatology at the Cincinnati Children’s Hospital Medical Center. She opened by expressing appreciation for corticosteroids, stating that they save lives. She provided important historical context: before the advent of corticosteroids, children died from complications of SLE within 20 months.13 She displayed striking images of patients with various manifestations of severe disease, illustrating the important role that corticosteroids play in limiting patient suffering.

Dr. Brunner cited additional benefits of corticosteroids: They are affordable, fast acting and effective. At an immune level, they are a jack of all trades, affecting numerous inflammatory pathways, such as blocking neutrophil adhesion, preventing cytokine release from monocytes and blocking T cell maturation.

In agreement with Dr. von Scheven, she emphasized that we are lacking data on how to manage low-dose prednisone, perhaps rooted in the complexity of the steroid receptor, and made more challenging by the concepts of steroid resistance and tolerance seen in some patients.

She focused the remainder of her argument on the risk of flare, emphasizing that stopping corticosteroids in DORIS remission offered no protection against flares, and highlighted the association between flare and reductions in quality of life and significant healthcare associated costs for patients and their families.14-16

In her closing arguments, she shared data showing that 5 mg of prednisone daily leads to a fourfold annual reduction in moderate to severe flares in patients with quiescent SLE, without an associated increase in infection or damage.17 She also called attention to a statement from EULAR emphasizing that steroid-related harm is dose dependent, and that doses of 5 mg or less are associated with an acceptably low risk of harm.18

In Sum

After both presentations, live audience polling data didn’t budge, re-demonstrating that about 60% of attendees favored an attempt at tapering prednisone. Ultimately, corticosteroid tapering requires a careful weighing of the risks and benefits of doing so and is dependent on a number of complex variables, including the SLE phenotype, burden of steroid toxicity, and patient and provider comfort with risk.

The session closed with a joint call to action, advocating for an attempt at tapering when feasible, bearing in mind patient preferences. The speakers also encouraged future research focusing on heterogeneity in response to corticosteroids, as well as new steroid-sparing agents.

Michael Cammarata, MD, RhMSUS, is an assistant professor of medicine at the Johns Hopkins University School of Medicine in Baltimore.

References

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