Starting dose is usually 40 mg of prednisone with breakfast for two to four weeks. If the disease is poorly controlled, the dose may be increased to 60 to 80 mg daily but blood pressure, serum glucose and side effects will require careful monitoring. Once controlled, the dose of steroids should be reduced by half for at least two weeks. Further reduction will depend on the break-through dose, the severity of the underlying skin disease and the availability or efficacy of steroid-sparing agents. The dose of long term prednisone should be as low as possible, as for other chronic diseases, and if possible taken on alternate days.
Tumlin et al (2013) reported on an open-label pilot trial of Acthar gel in patients with advanced diabetic nephropathy. A total of 23 patients with diabetic nephropathy were randomized to daily subcutaneous (SQ) injections of 16 or 32 units of Acthar gel for 6 months. The primary end-point was the percentage of patients achieving a complete remission (less than 300 mg/24 hours) within 6 months. Exploratory end-points included the percentage of partial (50 % reduction) remissions, changes in Cr, and urinary cytokine markers. After 6 months of Acthar gel therapy, 8 of 14 (57 %) patients achieved a complete (n = 1) or partial (n = 7) remission. In the low-dose ACTH gel group (16 units), urinary protein fell from 6,709 + 953 to 2,224 + 489 mg/24 hrs (p < ). In contrast, 2 of 6 patients in the 32-unit group achieved partial remission, but aggregate proteinuria (5,324 + 751 to 5,154 + 853 mg/24 hours) did not change. Urinary VEGF increased from 388 to 1,346 pg/mg urinary creatinine (p < ) in the low-dose group but remained unchanged in the high-dose group.