Reducing steroid exposure in systemic lupus erythematosus (SLE) requires evaluating disease control and treatment risks, as well as acknowledging and addressing patient and provider concerns. As discussed at the recent RhAPP Seventh Annual National Conference 2026, disease-modifying therapies and careful monitoring can support steroid tapering.

Following this presentation, featured expert Amanda Mixon, PA-C, was interviewed by Conference Reporter Associate Editor-in-Chief Christopher Ontiveros, PhD. Clinical perspectives from Ms Mixon on these findings are presented here.

In rheumatology, many of us use steroids to treat different diseases, and they can be life-saving medications. However, patients who are on steroids long-term can develop complications, including diabetes, osteoporosis, and cataracts. We need to have informed conversations with our patients up front so they understand that, while steroid therapies can help, we want patients to be on them for the shortest amount of time needed to treat the disease aggressively and appropriately while also trying to mitigate some of their associated risks. The guidelines tell us that we should try to get our patients down to 5 mg or less of prednisone daily, as safely and effectively as we can, by using other therapies, including hydroxychloroquine and some of the newer ones.

We do not need to use steroids in every patient with SLE, but we often will use steroids up front for those with more serious disease manifestations, depending on which organ system is involved. However, before starting therapy, we need to make sure that we are addressing any potential risks. Do we have a bone density test on the patient? Additionally, we need to know whether the patient has comorbid conditions that could be affected by chronic steroid use, such as diabetes, cardiovascular disease, osteoporosis, or cataracts. We need to be working closely with their other providers so that we can try to mitigate these risks. Setting realistic expectations with patients is also important. Some people may feel good on steroids, but others may have side effects from treatment, such as not sleeping well or feeling anxious.

At RhAPP 2026, Jeannette Hart, PA-C, did a really nice job of talking about how we need to consider initiating biologic therapy earlier for patients with SLE and be quicker to reevaluate therapy vs just keeping patients on the therapies they have been taking, including chronic steroids.

SLE is a very heterogeneous disease. You have to understand the manifestations your patient started with when you first made the diagnosis. Was it a cutaneous or an arthritic manifestation, or was there renal involvement? This helps frame when to start tapering. You also have to consider all facets: the patient sitting in front of you and what they are telling you, what you see when you examine them, and their laboratory test results. When the physical examination and test results look better and the initial disease manifestations have improved, it may be time to safely start tapering.

Additionally, we have to think about the dose and duration of the patient’s steroid therapy. Steroids can suppress the body’s own cortisol production, so you have to safely reduce steroids in a way that takes adrenal function into account. It comes down to how high the dose is and how long the patient has been on it. These are some key factors that help guide me in terms of how slowly I will taper steroid therapy.

It is important to meet patients where they are and to understand that, often, they have been struggling for a very long time. Then they finally get on this steroid medication that helps them. They feel better and their test results look better, so they may be scared to taper off this therapy. We have to take the time to have these discussions and address patients’ fears. Moreover, sometimes the fear of tapering steroid therapy comes from the provider. Providers may worry, “If I taper this patient off steroids, are they going to flare and have some terrible disease manifestation leading to hospitalization or dialysis?” Even though we do have more therapies than we did 10 years ago, I think that it is important to acknowledge and address these concerns.

The American College of Rheumatology (ACR) guideline for the treatment of SLE is very helpful. As you start to taper steroid therapy, the manifestations that you were initially treating could start to come back, so you also need to have a disease-modifying therapy in place that would allow you and the patient to be comfortable with moving forward with an appropriate steroid taper.