Glucocorticoids have been a mainstay of treatment for individuals with systemic lupus erythematosus (SLE). However, the risks associated with glucocorticoids are changing the way that these agents are used in SLE. At the recent ACR Convergence 2024 meeting, the epidemiology of glucocorticoid use and glucocorticoid-sparing treatments were topics of interest and discussion.

Following these presentations, featured expert Anca D. Askanase, MD, MPH, was interviewed by Conference Reporter Associate Editor-in-Chief Christopher Ontiveros, PhD. Dr Askanase’s clinical perspectives on these findings are presented here.

Steroids were first introduced in autoimmune diseases in the early 1950s after Edward Calvin Kendall, Philip Showalter Hench, and Tadeus Reichstein jointly received The Nobel Prize in Physiology or Medicine for the discovery of corticosteroids and their therapeutic use in the treatment of autoimmune diseases. It was a big disease- and life-changing event. Soon after that, physicians quickly understood the risks associated with chronic corticosteroid use, yet it took us nearly 7 decades to actually have the tools to start thinking about significantly decreasing corticosteroid use and to fully understand that some of the doses that we have used in the past 10 to 15 years may still be too high for many patients with SLE. We now understand that there is no steroid dose that is safe. Every dose carries some risk of damage accrual. Even doses that are less than 5 mg daily are associated with an increased risk of damage accumulation over time. The higher the dose, the higher the risk.

The 2023 European Alliance of Associations for Rheumatology (EULAR) guidelines were the first to highlight the need to reduce corticosteroid use to the lowest possible dose. The EULAR guidelines propose that the goal of treatment for people with SLE is remission that is associated with a steroid dose of less than or equal to 5 mg, when needed. However, ideally, steroids should be withdrawn, if possible. Traditionally, we often allow people to stay on 5 mg of prednisone or the equivalent. So, we have been permissive in allowing some long-term glucocorticoid use. However, I think that we are becoming more and more aware that even low doses of glucocorticoids carry a risk, and the goal needs to be to withdraw steroids completely in patients with SLE.

I believe that this paradigm is about to change as we come to better understand how to effectively use advanced therapies in SLE. An abstract by Mariana González-Treviño, MD, and colleagues presented at ACR Convergence 2024 highlighted this evolution in terms of the need to use steroids more sparingly (abstract 2421). It discussed reducing and discontinuing steroids when possible and using them as a bridge rather than as a long-term treatment, although this epidemiological study did not find this treatment approach to be widely occurring just yet.

To their credit, the EULAR guidelines also highlight the fact that we need to start thinking about quickly and promptly introducing biologics and immunosuppressants when people are not responding to hydroxychloroquine and steroids. The wisdom behind this is that you introduce the immunosuppressant as quickly as you can so that, as you are tapering off the steroids, the immunosuppressant provides that background of lowering autoimmune responses so that you are able to taper steroids safely.

I think it has become very clear that, in the treatment of SLE, starting biologics early may allow for the best control and the least amount of steroid use, as was demonstrated with the early introduction of biologic agents (ie, belimumab, anifrolumab, or rituximab) for SLE treatment in another abstract presented at this year’s ACR meeting (abstract 0667). In this study, the authors found that early introduction of biologics within the first 6 months suppressed disease relapse and enabled a reduction in the steroid maintenance dose. Findings on anifrolumab were also presented at ACR Convergence 2024, showing reduced steroid use within the first 6 months of initiating anifrolumab therapy (abstracts 1495 and 2438). These data highlight the window of opportunity that we have to introduce biologics early in the disease course to allow for disease modification and steroid-sparing treatment.