‘Get rid of maintenance prednisone’: Steroid-sparing critical for non-renal lupus
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Although patients with lupus nephritis may require prednisone maintenance, attempts should be made to reduce their steroid doses, said a speaker at The Future of Systemic Lupus Erythematosus Diagnosis and Treatment meeting.
“Steroid use is no longer necessary for non-renal lupus,” Michelle Petri, MD, MPH, professor of medicine at Johns Hopkins University School of Medicine, in Baltimore, said in her presentation. “We need to remove prednisone from the mainstay of treatment for non-renal lupus.”
According to Petri, the adverse outcomes associated with prednisone use outweigh the clinical benefits they confer.
For example, Petri noted that a month of high-dose maintenance prednisone can lead to an increase in avascular necrosis.
“The patient will pay the price forever,” she said.
Cardiovascular outcomes and osteoporotic fractures are also more likely in patients treated with steroids.
“For osteoporotic fractures, it really is all a prednisone story,” Petri said. “I always want to concentrate on cardiovascular damage, because it is a top five cause of death in our patients.”
The adverse impacts of long-term steroids include not only adverse clinical outcomes, but negative financial outcomes as well.
“If we could eliminate maintenance prednisone, we could eliminate significant insurance costs of caring for our lupus patients,” Petri said. “We need to push the prednisone taper.”
Although zero prednisone would be an ideal goal to minimize downstream effects, Petri acknowledged that this may not be a realistic goal while attempting to achieve Lupus Low Disease Activity State (LLDAS) or the 2021 definition of remission in SLE (DORIS) measures of disease activity.
“Maybe we will have to compromise that 5 mg is allowed because maybe some of the patients will have renal insufficiency,” she said.
However, not all patients can be treated effectively with such low steroid doses, Petri added.
“Where we get stuck is lupus nephritis,” she said.
Petri acknowledged that limited treatment options and the efficacy of steroids in the lupus nephritis population may force clinicians to continue this approach for the time being. However, she suggested that ongoing research should explore steroid-reducing strategies even in this group.
“I think we can get rid of maintenance prednisone for non-renal lupus,” Petri concluded. “Are we going to keep poisoning our patients to get the best renal response? What a terrible tradeoff that would be.”
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Petri M. Steroid Use in SLE: A Necessary Evil? No for Non-renal. Presented at The Future of Systemic Lupus Erythematosus Diagnosis and Treatment: A Discussion with the Experts; May. 7, 2022. (virtual meeting).
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