How do you approach the use of steroids for active muscle disease in patients with scleroderma-myositis overlap syndromes?

For patients with mild myopathy (mild weakness and CPK elevation), I tend to avoid steroids altogether if I can and just treat them with other therapy (like MMF or MTX). For patients with severe myopathy, particularly if they are very weak or have oropharyngeal weakness and at risk for aspiration, I will treat with steroids, including pulse dose steroids if needed. I counsel patients about the risk of scleroderma renal crisis in the setting of steroid treatment and have the patients monitor their blood pressure very closely (daily if they can), while they are on higher dose steroids. I do not prophylactically treat these patients with ACE inhibitors as this has not been shown to improve outcomes (and may even be associated with worse outcomes).