Induction treatment of lupus nephritis: to pulse or not to pulse? Whether ’tis nobler to universally or selectively prescribe

Current guidelines promoting pulse therapy for all forms of proliferative LN (and in the case of American College of Rheumatology 2024 treatment guidelines, even isolated class V membranous LN) rely on structured evidence grading processes, including expert consensus and observational data, but are not based on head-to-head randomised controlled trial comparisons. Therefore, there can be an ongoing debate regarding the best approach. The SLR identifies a distinct pharmacological benefit unique to pulse treatment, though without direct evidence necessary for the treatment of LN; includes observational studies with evidence of superior efficacy, but not consistently; and identifies a higher risk of adverse effects. In our opinion, the data advocates for a more selective approach to treatment, foregoing universal treatment with pulse steroids, based on a toxicity versus benefit assessment that patients with mild disease do not require the additional risks.