In a patient with strong serologic evidence of SLE presenting with isolated bilateral lower limb sensorimotor neuropathy, normal neuroimaging, and CSF, would you initiate cyclophosphamide with pulse-dose steroids upfront, or reserve escalation (e.g., plasma exchange or immunosuppressants) for cases refractory to steroids?

This has been a dilemma for me for over several decades.

1. There is no good large data to guide us on this question. I do not think there is one correct answer.

2. All sensorimotor neuropathies are not created equally. I assume all other causes of sensorimotor polyneuropathy have been ruled out. However, many of our patients have other potential causes (prediabetes, obesity, peripheral vascular disease, older age, etc) that it can be hard to know if the polyneuropathy is truly due to SLE or not (...