What steroid and dosage is recommended for a patient with a lupus (Systemic Lupus Erythematosus) flare-up upon discharge from the emergency room?

From the Guidelines

For a patient with a lupus flare being discharged from the emergency room, I recommend prescribing prednisone at a dose of 0.5-1 mg/kg/day (typically 30-60 mg daily for an average adult), taken once daily in the morning for 1-2 weeks, followed by a gradual taper over 4-8 weeks depending on symptom response. This recommendation is based on the 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus, which suggests that glucocorticoids can be used at doses and route of administration that depend on the type and severity of organ involvement 1.

The use of prednisone in this context is supported by the study, which notes that pulses of intravenous methylprednisolone (usually 250–1000 mg per day, for 1–3 days) provide immediate therapeutic effect and enable the use of lower starting dose of oral GC 1. However, for chronic maintenance treatment, GC should be minimized to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn 1.

Key considerations for the prescription include:

• The patient should take the medication with food to minimize gastrointestinal side effects
• Calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation should be prescribed to prevent steroid-induced bone loss
• The patient should be advised to follow up with their rheumatologist within 1-2 weeks to assess response and adjust the tapering schedule as needed
• Potential side effects, including mood changes, increased appetite, fluid retention, and elevated blood glucose, should be discussed with the patient

It is essential to note that the goal of treatment is to aim at remission or low disease activity and prevention of flares in all organs, maintained with the lowest possible dose of glucocorticoids 1. Therefore, the patient's response to the treatment should be closely monitored, and adjustments made as necessary to minimize the risk of side effects and maximize the effectiveness of the treatment.

From the FDA Drug Label

The initial suppressive dose level should be continued until satisfactory clinical response is obtained, usually four to ten days in the case of many allergic and collagen diseases. More severe disease states usually will require daily divided high dose therapy for initial control of the disease process

The patient with lupus flare up should be prescribed prednisone (PO) with a daily divided high dose for initial control of the disease process. The duration of treatment should be 4 to 10 days to obtain a satisfactory clinical response 2.

• The exact dosage is not specified in the drug label, and it is recommended to individualize and tailor the therapy to each patient.
• It is important to keep the period of initial suppressive dose as brief as possible.

From the Research

Steroid Treatment for Lupus Flare-Up

• The steroid commonly used to treat lupus flare-ups is prednisone 3, 4, 5, 6.
• The optimal dosage of prednisone for lupus flare-ups is not well established, but studies suggest that doses below 30 mg/day may be effective and safer than higher doses 5, 6.
• A study comparing high versus low-medium prednisone doses found that patients who received low-medium doses (≤30 mg/day) had similar SLEDAI score improvements as those who received high doses (>30 mg/day), but with less damage accrual 5.
• Another study found that higher initial prednisone doses (≥40 mg/day) achieved better complete renal response rates at 12 months, but cumulative glucocorticoid dose and damage accrual were not different at 2 and 3 years after lupus nephritis diagnosis 6.

Dosage and Duration

• The dosage of prednisone for lupus flare-ups can range from 10 mg/day to 60 mg/day, depending on the severity of the flare-up and the patient's response to treatment 3, 4, 5, 6.
• The duration of treatment with prednisone for lupus flare-ups can vary from a few days to several weeks or months, depending on the patient's response to treatment and the severity of the flare-up 3, 4, 5, 6.
• A study found that attempted taper to ≤7.5 mg/day prednisone or equivalent from Weeks 8-40 was required and defined as sustained reduction when maintained through Week 52 4.

Pharmacy Instructions

• Based on the available evidence, a suitable prescription for a patient with lupus flare-up in the emergency room upon discharge could be:

• Prednisone 20-30 mg/day for 7-14 days, with instructions to taper the dose by 5 mg every 3-5 days as symptoms improve 3, 5, 6.
• However, the optimal dosage and duration of treatment should be determined by a healthcare professional based on the individual patient's needs and response to treatment 3, 4, 5, 6.