The shifting sands of glucocorticoid use in SLE Save

ACR Convergence 2026 is officially underway, and rheumatologists are once again gearing up for an exciting season of learning, collaboration and networking. An immense amount of research shall be presented throughout the meeting, with SLE being one of them. 

Despite the rapid development of emerging therapies for SLE, glucocorticoids remain an important component of disease management. "How well do our current corticosteroid prescribing habits align with current treatment guidelines?" On day 1 of the SLE poster sessions, several abstracts have demonstrated notable trends in glucocorticoid utilization.  

Abstract 0262 by Dr. Sandino Bermudez et al. aimed to identify glucocorticoid (GC) exposure phenotypes by using group-based trajectory modelling on a national claims-based lupus nephritis cohort. The study period spanned more than 12 months with the index date corresponding to the first lupus nephritis treatment episode characterized by the earliest pulse/high dose GC exposure (>250 mg prednisone-equivalent on any day or oral prednisone-equivalent dose >25mg/day given >14 days) or new immunosuppressive therapy with mycophenolate, cyclophosphamide, calcineurin inhibitors, belimumab or rituximab. 

Their findings identified four (4) distinct GC trajectories: group 1 – moderate initial dose/slow taper (43.5%), group 2 – low dose (30.9%), group 3 – high initial dose/fast taper (18.2%) and group 4 – persistently high dose (7.4%). The groups with the higher exposure trajectories (groups 1, 3 & 4) were associated with a higher number of prior hospitalizations and higher glucocorticoid prescriptions from nephrologists than rheumatologists.

Similarly, the group of Dr. Mariana Gonzalez-Trevino (abstract 0274) evaluated trends of glucocorticoid use over a 40-year period. The decades were grouped into 1976-1988, 1989-1998, 1999-2008 and 2009-2018. A look into the trends of glucocorticoid administration shows that most of the patients initiated glucocorticoid therapy using any route (73.9%) with oral GC use as the main route (69.3%) while the GC pulse (> 250mg/day) using any route was least utilized. The use of antimalarials and immunosuppressive treatment showed a consistent increase until the recent decade of study (<0.001 for both arms). 

According to their multivariate analysis, factors significantly associated with glucocorticoid initiation were lupus nephritis (HR 2.85, 95% CI 2.00-4.06), higher disease activity (HR 1.11, 95% CI 1.09-1.14) and greater comorbidity burden (Charlson >2: HR 1.39, 95% CI 1.06-1.81). Whereas lupus nephritis and male sex were the strongest predictors of >5g exposure during the first year of treatment (HR 6.73, 95% CI 4.24-10.67 and HR 2.75, 95% CI 1.67-4.51, respectively). 

Meanwhile, from the other side of the globe, a retrospective analysis by Dr. Zhouli Zhang similarly evaluated secular changes in glucocorticoids exposure, background therapy and 12-month outcomes in the STAR cohort. Patients with active SLE, defined as baseline SLEDAI > 8 or prednisone-equivalent GC dose >40 mg/day were enrolled from 2007 to 2026. Cohort eras were grouped as follows: 2007 – 2012, 2013 – 2018 and 2019-2026. 

There was a significant decrease in the initial mean glucocorticoid dose from the earlier to the latest era (57.4mg/day, 56.9mg/day and 44mg/day). By month 12, mean glucocorticoid doses continued to decrease from 2007 to 2026 (12.9mg/day, 10.4mg/day and 6.9mg/day, respectively [p<0.001]. The group also noted a significant increase in the use of hydroxychloroquine and mycophenolate while the use of cyclophosphamide significantly declined. The attainment of LLDAS was reported at 19%, 28.9% and 59.7% at month 12 while similar trends were also seen in DORIS remission as the contemporary year approached (8.5%, 4.4% and 33.8%). 

These studies illustrate how glucocorticoids continue to play a role in the rapid control of disease with varying doses and routes, including the decline in its high dose/cumulative dose use through the years as immunosuppressive treatments are initiated early and newer therapies become available for SLE. Therefore, optimizing glucocorticoid prescribing strategies ensures therapeutic targets are met while minimizing complications.