From the Guidelines
For adults with minimal change disease (MCD), the recommended initial steroid regimen is oral prednisone at a dose of 1 mg/kg/day (maximum 80 mg daily), given as a single morning dose for 4-16 weeks until complete remission is achieved. This recommendation is based on the most recent and highest quality study available, which suggests that high-dose corticosteroids should be maintained for a minimum period of 4 weeks if complete remission is achieved, and for a maximum period of 16 weeks if complete remission is not achieved 1. The initial dose and duration of corticosteroids can be used for both the initial episode and infrequent relapses of MCD 1.
Key Considerations
- The dose of prednisone should be tapered gradually over 6 months to minimize relapse risk, with a typical tapering schedule reducing prednisone by 5-10 mg every 1-2 weeks until reaching 20 mg/day, then slowing the taper further (2.5-5 mg reductions every 2-4 weeks) 1.
- Patients should be monitored for proteinuria during the taper, as rapid reductions may trigger relapse.
- Steroid-related side effects should be anticipated and managed, including glucose monitoring, bone density assessment, gastrointestinal protection with proton pump inhibitors, and prophylaxis against Pneumocystis jirovecii pneumonia for high-risk patients.
- For patients who relapse or develop steroid dependence, steroid-sparing agents like calcineurin inhibitors (cyclosporine, tacrolimus) or rituximab may be considered as second-line therapy.
Special Considerations
- For patients with relative contraindications or intolerance to high-dose corticosteroids (e.g., uncontrolled diabetes, psychiatric conditions, severe osteoporosis), alternative treatments such as oral cyclophosphamide or calcineurin inhibitors may be considered 1.
- Statins should not be used to treat hyperlipidemia, and ACE-I or ARBs should not be used in normotensive patients to lower proteinuria in the initial episode of nephrotic syndrome associated with MCD 1.
From the Research
Steroid Dosing for Minimal Change Disease in Adults
- The optimal steroid dose for treating minimal change disease (MCD) in adults remains unclear, with studies suggesting that higher doses may not necessarily lead to better outcomes 2.
- A retrospective cohort study found that among patients in complete remission with a prednisolone dose <10 mg/day, higher steroid doses (PSL >20 mg/day) were not associated with favorable outcomes after the first relapse compared to lower doses (10-20 mg/day) 2.
- A randomized controlled trial compared tacrolimus monotherapy with prednisolone monotherapy for adults with de novo MCD and found no significant differences in complete remission rates or relapse rates between the two groups 3.
- Another study compared different treatment options for frequently relapsing or steroid-dependent MCD in adults and found that patients treated with rituximab may be less likely to require a change of therapy and more likely to come off immunosuppressive drugs 4.
- A systematic review of interventions for MCD in adults with nephrotic syndrome found that compared to prednisolone alone, calcineurin inhibitors with reduced-dose prednisolone or without prednisolone probably make little or no difference to the number achieving complete remission, but may reduce the risk of steroid-associated adverse events 5.
Treatment Options
- Corticosteroids, such as prednisolone, are the mainstay of therapy for MCD, but steroid-sensitive forms frequently relapse and may require second-line steroid-sparing immunosuppression 6.
- Alternative treatment options, such as tacrolimus, mycophenolate mofetil, and rituximab, may be effective for patients with MCD, particularly those who are steroid-dependent or frequently relapsing 3, 4, 5.
- The choice of treatment should be individualized based on the patient's specific needs and circumstances, and further research is needed to determine the optimal treatment strategies for MCD in adults 5.