Low dose steroids in SLE (Reflections from the Lupus SIG)

I recently attended the Lupus Special Interest Forum held last 30 May at the CME Auditorium, UST Hospital. One of the topics I was looking forward to was the one given by Prof. Guillermo Luis-Irastorza (Cruces University Hospital, Spain) during the recent Lupus Academy on using low doses of glucocorticoids in managing SLE.

He started by reviewing how steroids take effect and differentiated genomic vs. non-genomic mechanisms of action. When steroids are given in usual (oral) doses, we observe its genomic effects – which is also responsible for many of the adverse events we see. However, when pulse steroids are given, doctors are usually after the much faster non-genomic effects in reducing inflammation. Several studies were shown on how cumulative high doses of steroids were ultimately responsible for many of the organ damage observed in SLE patients. However, he also pointed out that pulse GCs minimally contribute to damage. He then proceeded to mention that the main reason why we have such patterns of steroid use in SLE is because it’s been the way things have been over the last 60 years. No head on trials have shown that lower doses of steroids work better compared to what we usually give. (What surprised me during this part is his avoidance of protocol to present steroid dose in relation to body weight i.e. mg/kg/day).

Professor Irastorza pointed out that at 30mg Prednisone, genomic receptors are 100% saturated. Non genomic mechanisms start at doses above this and are also 100% saturated when giving 250mg  Prednisone. He then proceeded to present several of his works demonstrating similar efficacy of low with higher doses of steroids with much less toxicity observed in the former. The papers were from a single center’s experience.

So how does Professor Irastorza use steroids in SLE? Here’s from his presentation.

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Obviously, he frequently gives pulse steroids to patients regardless of disease severity – but the dose differs for those with low-to-moderate (125-250mg M-Pred x 3 days) and severe (250-500mg M-Pred x 3 days) disease flares. Severe flares are an indication for EARLY initiation of immunosuppressive agents. More so, he mentioned that before he administers Pulse CTX monthly for lupus nephritis, he STILL gives 250mg M-Pred. And, likewise, if patients would need to be on >5mg prednisone for prolonged periods of time , he’d also give immunosuppressants. He also is very quick in tapering steroids (2.5 – 5mg every 2-4 weeks). All of his SLE patients are on HCQ which has become common practice in the last 10 years or so.

Not surprisingly, he is able to control disease activity with lower doses of steroids due to his avid use of pulse GCs and steroid sparers. This is a very doable system in practice. However, in the Philippines, the trade off will be costs.

Generic GCs are available for under Ph P 5.00 (roughly US $ 0.12). However, generic brands of HCQ cost Ph P 50.00 (US $ 1.20); Azathioprine costs Ph P 45.00 (US $ 1.00); and, MMF costs Ph P 75.00 (US $ 1.67). In a country where the daily minimum wage is around US $ 10-12, early initiation of steroid sparers and routine use of HCQ may be prohibitive. If we talk about pulse GCs, 1g M-Pred is around Ph P 4,500.00 (US $100.00). We haven’t even factored in the amount needed for being admitted for drug administration (Infusion centers are not that common here).

These medications are not currently supported by the national insurance system (PhilHealth) as most packages are for admitted cases. So until prices of these meds go down or insurance/ HMOs starts covering this, many Filipino patients may still have to deal with traditional steroid practices in SLE and the side effects that come with it.

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