Systemic lupus erythematosus (SLE) is a complex autoimmune disease, characterized by a wide spectrum of clinical manifestations and severity, with a clinical course usually marked by remission and relapses. Damage is a main prognostic predictor of SLE, thus preventing damage accrual is a major goal in these patients [1]. Since the 1950s, glucocorticoids (GCs) have been considered one of the cornerstones of lupus therapy, after the successful introduction of cortisone to treat rheumatoid arthritis by the Mayo Clinic rheumatologist Philip Hench in 1948 [2]. However, it was shown over the following decades that the miraculous efficacy of GCs was hampered by a large number of side effects, including accrual of irreversible organ damage by SLE patients, which has been convincingly linked to the prolonged use of oral GCs [[3], [4], [5]]. GC-related toxicity is largely dependent on the dose and the time of exposure. This has been clearly summarized in a recent systematic literature review, which has found that high average daily GC doses and high cumulative amounts are associated with the occurrence of cardiovascular events, osteoporosis with fractures and osteonecrosis [6]. The cutoff points of prednisone dose for the first month and for the first year of treatment related to damage at 5 years, calculated by receiver operating characteristic (ROC) curves, have been set at 32.6 and 7.38 mg/d, respectively [7].

However, and despite these well-known adverse-effects profile of long-term GCs use, they continue to be the first line therapy recommended by guidelines in management of SLE. Hence, there is an urgent need for different therapeutic schedules of GCs that can achieve a rapid and longstanding control of lupus activity while reducing related undesirable effects.

The aims of this review are to update the current evidence about the optimal doses of GCs, both for treating active disease and as maintenance of remission therapy, based on pharmacological and clinical evidence, and to offer a practical approach regarding the use of GCs in SLE.