Glucocorticoid-free treatment of systemic lupus erythematosus: is it feasible?

Glucocorticoids (GCs) remain the mainstay of treatment in systemic lupus erythematosus (SLE) more than 60 years after their discovery. Despite their effectiveness in controlling disease activity, the long‑term use of GC often causes side effects that increase morbidity and mortality in SLE patients. Evidence from randomized controlled trials on the appropriate dosing and tapering of GC in SLE is scarce. Historically, high doses of GC were used in the treatment of SLE. Fortunately, there are emerging data showing a lower dose of GC is equally effective compared to a higher GC in controlling disease activity and has fewer adverse effects. The introduction of various GC‑sparing immunosuppressive (IS) treatments such as cyclophosphamide (CYC), azathioprine, mycophenolate mofetil, calcineurin inhibitors, and biologic agents has assisted in reducing the GC doses in SLE. The aims of this narrative review are to give an overview on the GC mechanisms of actions, the strategies to reduce GC‑related toxicity, the evidence of low GC dose protocols and finally to discuss the viability of GC‑free treatment of SLE.