What is the management approach for a patient after high dose prednisolone (corticosteroid) therapy, particularly for Focal Segmental Glomerulosclerosis (FSGS)?

Management After High-Dose Prednisolone for FSGS

After achieving remission with high-dose prednisolone in FSGS, taper the dose by 5 mg every 1-2 weeks to complete a total treatment duration of at least 6 months. 1

Tapering Strategy Based on Response

If Complete Remission Achieved Rapidly

• Continue high-dose glucocorticoid treatment for 4 weeks OR after the disappearance of proteinuria, whichever is longer 1
• Then reduce prednisone by 5 mg every 1-2 weeks to complete a total duration of 6 months 1
• The total treatment duration must be at least 6 months even if remission occurs early 1

If Partial Remission Achieved Within 8-12 Weeks

• Continue high-dose glucocorticoids until 16 weeks to determine whether further proteinuria reduction and complete remission may occur 1
• After 16 weeks, reduce prednisone by 5 mg every 1-2 weeks to complete a total duration of 6 months 1
• Do not persist with high-dose therapy beyond 16 weeks, as additional benefit is unlikely in FSGS patients 1

If Steroid-Resistant or Significant Toxicities Develop

• Rapidly taper glucocorticoids as tolerated 1
• Switch to alternative immunosuppression with calcineurin inhibitors (CNIs) 1
• Cyclosporine: 3-5 mg/kg/day in 2 divided doses with target trough level 100-175 ng/ml 1
• Tacrolimus: 0.05-0.1 mg/kg/day in 2 divided doses with target trough level 5-10 ng/ml 1
• Continue CNI therapy for at least 4-6 months before considering treatment failure 1

Critical Monitoring During Taper

Proteinuria Assessment

• Monitor proteinuria regularly to evaluate treatment response 2
• Remission of proteinuria is the most significant predictor of renal survival in FSGS 3
• Patients who are likely to remit will show some degree of proteinuria reduction before 16 weeks 1

Kidney Function Monitoring

• Assess serum creatinine regularly during the taper phase 2
• If using CNIs, reduce dose if serum creatinine increases but does not plateau or increases over 30% of baseline 1
• If serum creatinine does not fall after CNI dose reduction, discontinue the CNI 1

Management of Relapses

Treat relapses with the same initial dose and duration of corticosteroids as the first episode 1

• Prednisone 1 mg/kg/day (maximum 80 mg) or alternate-day dose of 2 mg/kg (maximum 120 mg) 1
• Continue for minimum 4 weeks up to 16 weeks as tolerated or until complete remission 1
• For frequently relapsing disease, consider CNIs as steroid-sparing agents 1

Supportive Care Throughout Treatment

Cardiovascular and Metabolic Management

• Target systolic blood pressure <120 mmHg using standardized office measurement 2
• Initiate ACE inhibitors or ARBs at maximally tolerated doses for proteinuria and blood pressure control 2
• Restrict dietary sodium to <2.0 g/day to reduce edema 2

Infection Prevention

• Administer pneumococcal and influenza vaccines 2
• Consider prophylactic trimethoprim-sulfamethoxazole for patients receiving high-dose immunosuppression 2

Steroid Side Effect Prophylaxis

• Monitor for diabetes, particularly in obese patients or those with family history 1
• Assess bone health and consider prophylaxis for osteoporosis 1
• Screen for psychiatric side effects, especially in patients with pre-existing psychiatric disorders 1

Common Pitfalls to Avoid

• Do not stop high-dose steroids abruptly - always taper gradually over 6 months total duration 1
• Do not continue high-dose therapy beyond 16 weeks if proteinuria is persistent and unremitting, especially with side effects 1
• Do not use CNIs without monitoring trough levels to minimize nephrotoxicity 1
• Do not assume treatment failure before 16 weeks unless severe toxicities develop 1