Higher initial prednisone doses for remission induction in patients with new-onset lupus nephritis (LN) achieve better complete response (CR) rates compared with lower initial doses, according to a recent study.

The study included 206 patients with new-onset LN and standard immunosuppressive treatment. Investigators divided patients into a low-dose prednisone group (30 mg/d or less) and high-dose prednisone group (40 mg/d or more). The 103 patients in each group were matched by propensity score. The high-dose and low-dose groups had a mean prednisone dose of 48.6 and 24.2 mg/d, respectively.

The investigators defined CR as proteinuria less than 0.5 g/d and no worsening of kidney function.

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The CR rate was significantly higher in the high-dose than low-dose group at 12 months after LN diagnosis (61.8% vs 38.2%), Murray B. Urowitz, MD, of the University of Toronto Lupus Clinic in Toronto, Ontario, Canada, and colleagues reported in Arthritis Care & Research. CR rates also were significantly higher in the high-dose group at 2 years (67.8% vs 39.0%) and 3 years (64.9% vs 49.1%) after diagnosis, according to the investigators.

Dr Urowitz and colleagues also found superior CR rates with high-dose prednisone in some subgroups, including patients with proliferative LN (65.8% vs 26.8%), those who received concomitant remission induction with mycophenolate mofetil or cyclophosphamide (68.0% vs 36.0%), and those who initiated treatment after 2003 (61.4% vs 36.6%). High-dose prednisone did not improve CR rates among patients with nonproliferative LN, those who received concomitant remission induction with azathioprine, and those treated before 2003.

At 2 and 3 years, both groups had a similar cumulative glucocorticoid dose and accrual of glucocorticoid-related damage.

Both groups experienced an accelerated rate of glucocorticoid-related damage at 2 and 3 years following LN diagnosis, “underlying the importance of rapid tapering and the need for implementation of alternative strategies to reduce adverse events without sacrificing efficacy,” the authors wrote.


Tselios K, Gladman DD, Al-Sheikh H, et al. Medium versus high initial prednisone dose for remission induction in lupus nephritis: a propensity score matched analysis. Published online March 4, 2021. Arthritis Care Res. doi:10.1002/acr.24592