Corticosteroid and Nonsteroidal Anti-Inflammatory Drug use in Systemic Lupus Erythematosus

Corticosteroids have been the mainstay of therapy for systemic lupus erythematosus since the 1950s. Over time the specific preparations, dosage, and routes of administration have changed, but their use for virtually all clinical organ system manifestations of lupus have been described. This chapter briefly discusses the biologic mechanisms of action of steroids and considers their association with the temporal improvement in survival. We review the data on steroid efficacy for particular disease manifestations, including recommendations for induction therapy, prevention of lupus flares, and steroid-tapering regimens, including the use of alternate day administration and concomitant treatment with other immunosuppressive agents. The limitations of steroid use secondary to acute and long-term side effects are discussed. We also consider the efficacy and toxicity of non-steroidal anti-inflammatory agents. Shortly after Philip Hench introduced the use of cortisone for the treatment of rheumatoid arthritis in 1948, this revolutionary therapy began to be used in patients with severe systemic lupus erythematosus (SLE). By 1955, prednisone, a derivative of cortisone, was synthesized, and in February 1955, prednisone was approved for the treatment of SLE. Subsequently a number of other glucocorticoid (GC) preparations have been used to treat lupus, but none of these preparations or the regimens used have been specifically approved by the United States Food and Drug Administration (FDA). This chapter will discuss GC and non-steroidal therapy for SLE, including mechanism of action, dose regimens (intravenous pulse, alternate-day, tapering regimens) efficacy and toxicity, and use for specific clinical manifestations. In the absence of specific recommendations from the literature, we will make suggestions based on our experience with a large cohort of SLE patients dating from the early 1960s to the present (2010).