Glucocorticosteroids

Glucocorticosteroids have been shown to influence various parameters involved in inflammatory processes, including migratory and resident cells like lymphocytes, mast cells, and endothelial cells. Thus, activation and extravasation of immune cells as well as subsequent edema is reduced or blocked. The advent of glucocortico-steroids in the 1960s has grossly improved the so far poor prognosis of SLE. Even with the availability of modern immunomodulatory substances, glucocortico-steroids are still needed for their rapid and distinct clinical effects. Yet, their long-term side effects have to be counterbalanced by combination with other drugs that will result in steroid-sparing effects (Callen 2002, Goldberg and Lidsky 1984, Wallace 2002, Werth 2002).

Some authors strongly discourage the use of oral glucocorticosteroids for CLE because of low efficacy on one hand and known toxicity on the other (McCauliffe 2001). Furthermore, several good alternatives are available before resorting to oral glucocorticosteroids. With rapid-onset disease or rapid progress, initial short courses of glucocorticosteroids can be effective before antimalarial therapy becomes effective. Whereas SCLE may respond to oral glucocorticosteroids, there is lack of efficacy especially in DLE. Doses well below 1 mg/kg body weight may suffice and should be tapered within 3-4 weeks. For CLE, the latter regimen seems efficient in most cases. Methylprednisolone, at doses of 1 g intravenously daily for 3 days, was shown to clear otherwise refractory SCLE within 1-2 weeks, with sustained improvement for 2-3 months (Werth 1993, Goldberg 1984). Such pulse regimens of glucocorticosteroids are preferred by some authors for their dose-sparing effects, whereas others suggest daily intake of low steroid doses.

For steroid-sparing effects, agents like azathioprine (see below) may be added that support clinical effects induced by glucocorticosteroids while tapering steroid doses. Cases in which steroid doses below 0.5 mg/kg body weight result in relapses of disease are sometimes referred to as steroid resistant and need other regimens to be initiated, as outlined later herein.

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