Glucocorticoid (GC) therapy is very important in treating lupus patients. There is no other medication for systemic lupus erythematosus (SLE) to which response is comparable fast, and nearly all SLE manifestations seem to respond at least in some part to GC. Therefore GCs are regularly used in about two out of three SLE patients, and GCs are included in any management guideline for SLE. GCs are the initial medication in lupus flares and are therefore used in nearly all trials as induction therapy and tapered afterwards without a harmonized tapering strategy. No recommendation indicates clearly who and when to stop GC in SLE and attempts to evaluate the stopping of GC use do not find their patients and not supported by most physicians. Most physicians, at least in Germany, believe that SLE patients can to survive without GC therapy.
Over the last decade increasing evidence was collected that GCs independently of the classical acute and chronic side effects harm SLE patients. Mayor problems are infections and accelerated arteriosclerosis. Guidelines like the Eular recommendations advise the use of immunosuppressive medications like azathioprine, mycophenolate and methotrexate as GC sparing agents, although trials to support this concept are limited. But the number of RCTs that foster the use GCs in SLE is also rare, mostly caused by widespread use of GCs and the long history of clinical success with GCs.
From the clinical perspective, there are three mayor reasons for the abuse of GCs in SLE: 1. the induction of GC therapy is not driven by a clear indication which allows reducing and stopping GCs again when the problem is solved; 2. GCs are given in patients with doubtful diagnosis and indications, then continuously increased because of incomplete response and extended endless instead of trying to find the right diagnosis and 3. the fear to stop GCs completely, which is maintained by limited individual experiences. These three reasons have to be addressed in every case at every time to taper GCs significantly.
Disclosure of Interest M. Schneider Grant/research support from: GSK, UCB, Consultant for: Astra-Zeneca, GSK, Lilly, UCB, Speakers bureau: Astra-Zeneca, GSK, UCB