What is the recommended steroid therapy for a lupus (Systemic Lupus Erythematosus) flare?

Steroid Therapy for Lupus Flare

For lupus flares without major organ involvement, glucocorticoids at doses ≤30 mg/day of prednisone (or equivalent) should be used in combination with antimalarials, with the goal of tapering to ≤7.5 mg/day as quickly as possible. 1, 2

Treatment Approach Based on Flare Severity

Non-Organ Threatening Flares

• Initial therapy: Prednisone 0.5 mg/kg/day (maximum 30 mg/day) combined with hydroxychloroquine 1, 2
• Duration: Begin tapering after 4 weeks
• Tapering goal: Reduce to ≤10 mg/day by 4-6 months, then to ≤7.5 mg/day for maintenance 1
• Adjunct therapy: Consider NSAIDs for short periods in patients at low risk for complications 1

Severe/Organ-Threatening Flares

• Initial therapy: Three consecutive pulses of intravenous methylprednisolone 500-750 mg, followed by oral prednisone 0.5 mg/kg/day 1
• Additional immunosuppression: Add mycophenolate mofetil (MMF) or cyclophosphamide based on organ involvement 1
• For lupus nephritis: Combine glucocorticoids with immunosuppressive agents (cyclophosphamide, MMF, or tacrolimus) 1
• For neuropsychiatric lupus: High-dose glucocorticoids plus immunosuppressive therapy for inflammatory manifestations 1

Specific Organ Involvement Guidelines

Lupus Nephritis

• Class III/IV nephritis: Methylprednisolone pulses (500-750 mg IV × 3) followed by prednisone 0.5 mg/kg/day with MMF (target 3 g/day) or cyclophosphamide 1
• Class V nephritis: Prednisone 0.5 mg/kg/day with MMF (target 3 g/day) 1
• Maintenance phase: Taper to ≤7.5 mg/day prednisone while continuing immunosuppression 1

Neuropsychiatric Lupus

• For inflammatory manifestations (optic neuritis, acute confusional state, neuropathy, psychosis, myelitis): High-dose glucocorticoids plus immunosuppressive therapy 1, 3

Tapering and Maintenance

• Maintenance dose: Aim for ≤7.5 mg/day of prednisone or equivalent 1
• Duration: Consider maintaining 5 mg/day in patients with stable disease, as withdrawal increases flare risk (RR 0.2,95% CI 0.1-0.7) 4
• Complete discontinuation: May be attempted after ≥12 months of complete clinical response, but with careful monitoring 1

Important Considerations

Monitoring for Response

• Track clinical signs (rashes, arthritis, serositis, neurological manifestations)
• Monitor laboratory parameters (CBC, renal function, urinalysis, C3/C4, anti-dsDNA) 1
• Assess disease activity using validated indices

Minimizing Steroid-Related Damage

• Long-term risks: Infections, hypertension, hyperglycemia, osteoporosis, avascular necrosis, cataracts, glaucoma 5
• Prevention strategies:
  • Keep daily dose ≤7.5 mg/day when possible 1
  • Use steroid-sparing agents (antimalarials, immunosuppressants) 1
  • Consider calcium/vitamin D supplementation and bisphosphonates 1

Preemptive Treatment for Serologically Active Disease

• In clinically stable patients with rising anti-dsDNA and C3a levels, short-term prednisone (starting at 30 mg/day with 4-week taper) may prevent severe flares 6

Pitfalls to Avoid

• Using high-dose steroids (>30 mg/day) for non-organ threatening disease increases damage without improving efficacy 2
• Tapering too quickly may lead to disease flare
• Failing to add steroid-sparing agents when unable to reduce prednisone below 7.5 mg/day
• Not providing prophylaxis against steroid-related complications in high-risk patients

The evidence clearly shows that lower doses of prednisone (≤30 mg/day) are as effective as higher doses for treating active lupus while causing significantly less damage, particularly when combined with appropriate immunosuppressive and antimalarial therapy 2.