Pulse steroids: how much is enough?

High dose pulse intravenous steroids with 1 g of methylprednisolone (MEP) given daily, usually for three days, is an accepted practice to treat severe manifestations of systemic lupus erythematosus (SLE) or systemic vasculitides, despite the lack of definitive data. Most studies addressing the efficacy of high dose glucocorticoids (GCs) have been uncontrolled, retrospective or did not compare different doses. A limited number of studies comparing different doses of GCs suggest that lower doses of MEP given as intravenous pulse therapy might be as effective as the very high doses currently used. In addition, while early reports did not find serious adverse effects related to very high doses of steroids, several more recent studies indicate a high risk of serious infections proportional to the current or cumulative dose of GCs. While we await more conclusive studies addressing these questions, one might wonder whether we could be using too much of a good thing.