The burden of steroid use in systemic lupus erythematosus

The attitude towards using glucocorticosteroids (GCs) for the management of patients with systemic lupus erythematosus (SLE) has undergone drastic changes over the last decades. While the role of GCs for the rapid control of inflammation is uncontested, the former 'dogma' that GCs must never be withdrawn due to fear of severe flares was proven wrong and replaced by a strategy that invites both tapering GCs to 0 and questioning whether they even need to be initiated at all in individual patients. Moreover, the daily prednisone equivalent dose acceptable for long-term use is limited to ≤ 5 mg in current recommendations. These changes are a consequence of a substantial body of evidence that links higher GC doses to infections, cardiovascular events and other damage, and an increasing number of studies showing that GC withdrawal is feasible in many SLE patients who are in remission. Despite methodological concerns, with observational data inherently prone to confounding by indication, the worldwide experience of the last decades suggests that the limit of 5 mg daily is justified. Moreover, current strategies and novel medications have made it a reality for many SLE patients, to actually maintain the goal of remission or low disease activity on not >5 mg of prednisone per day.