Steroid Protocol for Active Vasculitis
For patients with active ANCA-associated vasculitis, use the weight-based PEXIVAS reduced-dose glucocorticoid tapering regimen, which provides equivalent efficacy to higher-dose protocols with significantly reduced toxicity. 1
Initial Dosing (Week 1)
The starting prednisolone dose is weight-based 1:
- <50 kg: 50 mg daily
- 50-75 kg: 60 mg daily
- >75 kg: 75 mg daily
Consider 1-3 days of intravenous methylprednisolone (500-1000 mg daily) before oral therapy for severe presentations, though recent evidence suggests lower IV doses (250 mg) may be equally effective with less toxicity 2.
Tapering Schedule (Weeks 2-52)
Follow this structured taper based on patient weight 1:
Weeks 2-4
- <50 kg: Week 2: 25 mg, Weeks 3-4: 20 mg
- 50-75 kg: Week 2: 30 mg, Weeks 3-4: 25 mg
- >75 kg: Week 2: 40 mg, Weeks 3-4: 30 mg
Weeks 5-12
Progressive reduction every 2 weeks 1:
- <50 kg: 15 mg → 12.5 mg → 10 mg → 7.5 mg
- 50-75 kg: 20 mg → 15 mg → 12.5 mg → 10 mg
- >75 kg: 25 mg → 20 mg → 15 mg → 12.5 mg
Weeks 13-22
Continue tapering to reach 5 mg daily by week 20-22 for all weight groups 1.
Weeks 23-52
Maintain 5 mg daily prednisolone 1.
Maintenance Phase (After 1 Year)
Continue glucocorticoids at 5-7.5 mg daily for 2 years total, then reduce by 1 mg every 2 months 1. This prolonged low-dose maintenance is critical for preventing relapse 1.
Special Considerations
Severe Renal Impairment (Creatinine >4 mg/dL)
For patients with severe glomerulonephritis, consider combining rituximab with 2 pulses of intravenous cyclophosphamide in addition to glucocorticoids, as there are limited data supporting rituximab alone in this population 1.
Alternative to Glucocorticoids
Avacopan 30 mg twice daily can replace glucocorticoids in patients at high risk for steroid toxicity, used in combination with rituximab or cyclophosphamide 1. Patients with lower GFR may benefit from greater renal recovery with this approach 1.
Large Vessel Vasculitis (GCA/Takayasu)
For giant cell arteritis or Takayasu arteritis, start with 40-60 mg daily prednisolone, taper to 15-20 mg within 2-3 months, and aim for ≤5 mg daily (GCA) or ≤10 mg daily (Takayasu) by 1 year 1.
Critical Pitfalls to Avoid
Tapering too rapidly increases relapse risk 3. The PEXIVAS reduced-dose regimen demonstrated that slower tapers beyond 6 months are necessary—patients maintained on 5 mg daily through week 52 had better outcomes 1.
Do not use traditional high-dose protocols (starting at 1 mg/kg daily with slower tapers). The PEXIVAS trial definitively showed the reduced-dose regimen has equivalent efficacy for mortality and ESKD with significantly fewer serious adverse events 1, 2.
Initiate bone protection and cardiovascular risk reduction immediately when starting glucocorticoids, as treatment-related complications significantly impact morbidity 1.
Monitor for infections vigilantly, particularly in the first 3 months when cumulative steroid exposure is highest 2. Consider PCP prophylaxis with trimethoprim-sulfamethoxazole 1.