What are the indications for pulse therapy in Systemic Lupus Erythematosus (SLE)?

From the Guidelines

Pulse therapy with high-dose intravenous methylprednisolone is indicated in severe, life-threatening manifestations of systemic lupus erythematosus (SLE), including lupus nephritis, neuropsychiatric lupus, severe thrombocytopenia, and other organ-threatening diseases, as recommended by the 2019 EULAR guidelines 1. The standard regimen consists of 250-1000 mg of methylprednisolone administered intravenously daily for 1-3 days, as stated in the guidelines 1. Specific indications for pulse therapy include:

• Lupus nephritis, especially class III or IV
• Neuropsychiatric lupus, such as seizures, psychosis, or myelitis
• Severe thrombocytopenia
• Hemolytic anemia
• Pulmonary hemorrhage
• Myocarditis
• Vasculitis Pulse therapy is also used when patients have failed to respond to conventional doses of oral corticosteroids or when rapid disease control is necessary, as recommended by the guidelines 1. Following pulse therapy, patients typically transition to oral prednisone (usually 0.5-1 mg/kg/day) with a gradual taper, along with appropriate immunosuppressive agents like cyclophosphamide, mycophenolate mofetil, or rituximab, depending on the organ involvement, as suggested by the guidelines 1. The use of pulse therapy is supported by the guidelines, which recommend minimizing chronic maintenance treatment with glucocorticoids to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawing them 1. It is essential to monitor patients for potential adverse effects, including hyperglycemia, hypertension, electrolyte abnormalities, and increased infection risk during treatment, as with any immunosuppressive therapy. The guidelines emphasize the importance of prompt initiation of immunomodulatory agents to expedite the tapering or discontinuation of glucocorticoids 1. Overall, pulse therapy with high-dose intravenous methylprednisolone is a valuable treatment option for severe, life-threatening manifestations of SLE, and its use should be guided by the 2019 EULAR guidelines 1.

From the Research

Indications for Pulse Therapy in SLE

• Pulse therapy, typically involving intravenous pulses of methylprednisolone, is used to treat severe manifestations of systemic lupus erythematosus (SLE) 2.
• The indications for pulse therapy in SLE include:
  • Lupus nephritis, particularly for induction therapy 3, 4.
  • Neuro-psychiatric lupus 2.
  • Pulmonary hemorrhage 2.
  • Severe blood dyscrasias 2.
  • Cardiomyopathy 2.
  • Vasculitis 2, 5.
• The use of pulse therapy in SLE is supported by clinical trials, although most studies are uncontrolled and retrospective 2.
• The optimal dose and duration of pulse therapy in SLE are not well established, with some studies suggesting that lower doses may be as effective as higher doses 5.
• Pulse therapy with methylprednisolone can be associated with significant side effects, including infections, particularly in patients with hypoalbuminemia 2.