Prednisolone dosage in pemphigus vulgaris

Abstract

To the Editor: We read with great interest the comprehensive CME article by Dr Mutasim in the December 2004 issue of the Journal on the management of autoimmune bullous diseases. The author presented prednisone 1 mg/kg as the first drug to manage pemphigus vulgaris and suggested the addition of adjuvant treatment in case of nonresponse or adverse effects. Although the very high dosage of prednisolone suggested by Lever is no longer recommended, to the best of our knowledge there is not yet a general consensus based on well-designed controlled trials on the optimum dosage schedule of steroids. Ratman in the only relevant controlled trial, compared low-dose (60 mg) versus high-dose (120 mg) prednisolone, but no long-term advantage of the high-dose regimen was noted; his study had a small sample size (only 22 cases were enrolled, 3 of whom had pemphigus foliaceus). Pemphigus vulgaris has a relatively high prevalence in our country, and in our clinical experience we prefer to start with 2 mg/kg prednisolone combined with an adjuvant drug (eg, azathioprine, mycophenolate mofetil, or cyclophosphamide), especially in moderate to severe cases. The dosage is reduced by 30% after clinical response (usually after 10-14 days), and then tapered by 10 mg/week until 30 mg and slower afterwards. Doses greater than 1 mg/kg are not abandoned in other centers, too, and to the best of our knowledge, even many experts who prefer treating pemphigus with prednisolone 1 mg/kg increase the dosage in a stepwise manner in the case of a lack of response after 5 to 7 days. It appears that until a general consensus based on controlled trials is reached, it is more feasible to still recommend a range of 1 to 2 mg/kg for prednisolone dosage tailored by the clinical severity and the patient’s general health status in pemphigus vulgaris.