Box 7 Prescription procedures for corticosteroid therapy

Corticosteroid therapy is the subject of many discussions on the most suitable regimen

The initial treatment usually includes corticosteroid therapy started at a dose of 1 mg/kg/day of a prednisone equivalent, capped, except in certain cases, at 60 mg/day, or even at lower doses of the order of 0.5 mg/kg/day in the event of discreet to moderate manifestations

An IV bolus of methylprednisolone can be given for 1–3 consecutive days, usually at a dose of 7.5–15 mg/kg/day (not to exceed 1 g/bolus), depending on severity and the patient’s cardiovascular condition, before following up with oral corticosteroid therapy at a dose of 1 mg/kg/day of a prednisone equivalent. This therapeutic method is to be reserved for clinical situations requiring a rapid therapeutic response. They are not useful in “cold” forms of the disease or when the clinical condition is progressive or not life-threatening or functionally threatening

After an initial treatment of 3 weeks at a dose of 1 mg/kg/day of a prednisone equivalent, the corticosteroids should be reduced. There is no internationally validated pattern of reduction. The total duration of corticosteroid therapy varies from 5 to 6 months (North American protocols) to 18–24 months (European protocols). It is proposed in France to follow, in the absence of a study available with sufficient follow-up, a regimen of reduction whose essential benchmarks are approximately 20 mg/day at 3 months, 10 mg/day at 6 months, and 5 mg/day at 1 year of a prednisone equivalent

The PEXIVAS protocol offers, after boluses of methylprednisolone and in combination with an immunosuppressant, a regimen of glucocorticoids at a reduced dose, with a rapid reduction in the corticosteroid therapy initially but maintaining a low dose for at least 12 months (see below). This regimen seems particularly worthwhile, but the composite criterion for judging based on mortality and/or chronic terminal kidney disease represents a very “hard” criterion. The hindsight remains modest and we have no information on the rate of minor or major relapses after this reduced-dose regimen