Glucocorticoid reduction in Glomerular Diseases

Glucocorticoids (GCs) remain central to the management of many glomerular diseases, providing rapid and potent antiinflammatory effects. However, their well-recognized toxicities have driven growing efforts to reduce cumulative exposure. This review synthesizes evidence from randomized and key noncontrolled studies evaluating GC-sparing strategies across diseases where these agents have historically played a central therapeutic role. In antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), large trials such as the Plasma Exchange and Glucocorticoids in Severe ANCA-Associated Vasculitis (PEXIVAS) trial and the Effect of Reduced-Dose versus High-Dose Glucocorticoids Added to Rituximab (LoVAS) trial demonstrate that reduced-dose regimens preserve efficacy while lowering infection risk. In lupus nephritis (LN), lower-dose strategies and early use of multipronged regimens incorporating targeted agents such as belimumab, calcineurin inhibitors, or obinutuzumab support faster tapering. In minimal change disease (MCD), combination approaches with calcineurin inhibitors or mycophenolate achieve remission with less steroid exposure. In IgA nephropathy (IgAN), practice is increasingly shifting away from GC use altogether, as novel immunomodulatory agents targeting disease-specific pathways are integrated into care. Although GCs will likely remain essential for induction in select inflammatory glomerulopathies, their role can increasingly be narrowed to early, time-limited use. Future studies should address key uncertainties, particularly the optimal use of i.v. methylprednisolone in rapidly progressive presentations and evaluate the safety and efficacy of even lower-dose regimens.