Glucocorticoid Use and Abuse in SLE
Glucocorticoid Use and Abuse in SLE
GCs are among the most potent immunosuppressive and anti-inflammatory drugs. Their efficacy in treating SLE is beyond doubt. However, GC-related side effects are many and serious. Indeed, prednisone use has been consistently shown to increase irreversible damage in lupus patients, a major predictor of morbidity and mortality.
Recent data have shown that many side effects are dose related, and closely linked with the degree of activation of the genomic pathway. In general, serious toxicity starts at doses of 7.5 mg/day, the limit between low and medium pharmacological doses. Moreover, the need for high doses of 1 mg/kg/day in severe lupus activity is now being questioned, since significantly lower doses may be equally effective. Finally, pulse methylprednisolone, 500 mg/day during three consecutive days, is a potent therapy for severe acute lupus flares with few associated side effects.
Every effort should be made to avoid GC side effects. It should be borne in mind that GCs are not the therapy of lupus, but part of the treatment of lupus manifestations. Concomitant use of anti-malarials and immunosuppressive drugs may help keep daily doses of prednisone <7.5 mg/day, or even to withdraw it. GC-induced osteoporosis should be prevented following available guidelines. Osteonecrosis may be reduced by avoiding high prednisone doses during the early phases of disease. In general, using GCs in a more restrictive way should help prevent major complications in patients with SLE.
Summary
GCs are among the most potent immunosuppressive and anti-inflammatory drugs. Their efficacy in treating SLE is beyond doubt. However, GC-related side effects are many and serious. Indeed, prednisone use has been consistently shown to increase irreversible damage in lupus patients, a major predictor of morbidity and mortality.
Recent data have shown that many side effects are dose related, and closely linked with the degree of activation of the genomic pathway. In general, serious toxicity starts at doses of 7.5 mg/day, the limit between low and medium pharmacological doses. Moreover, the need for high doses of 1 mg/kg/day in severe lupus activity is now being questioned, since significantly lower doses may be equally effective. Finally, pulse methylprednisolone, 500 mg/day during three consecutive days, is a potent therapy for severe acute lupus flares with few associated side effects.
Every effort should be made to avoid GC side effects. It should be borne in mind that GCs are not the therapy of lupus, but part of the treatment of lupus manifestations. Concomitant use of anti-malarials and immunosuppressive drugs may help keep daily doses of prednisone <7.5 mg/day, or even to withdraw it. GC-induced osteoporosis should be prevented following available guidelines. Osteonecrosis may be reduced by avoiding high prednisone doses during the early phases of disease. In general, using GCs in a more restrictive way should help prevent major complications in patients with SLE.
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