We'd like to start by thinking about: Our goal is to induce remission in a patient regardless of age group and then maintain a patient in remission, again, regardless of age group. We have limited therapies that induce remission. Steroids are a very important and very efficacious way of putting a patient into remission. Similarly, in children, the efficacy ranges anywhere from 60 to 80% as been shown in the adult population.

We know what the side effects of steroids are, we know what to anticipate and what to talk to the parents about. And we'd also talk to an adult the same way in terms of what deciphering what to expect in the short-term. And we don't necessarily talk about long-term in children in terms of the side effect profile, because we are very focused on what we need to do in terms of inducing remission in children and the fact that we're dealing with a very dynamic phase of a child's development-Growth-Developing strong and healthy bones and getting them to grow.

Now, steroids impact both the development of strong and healthy bones and, perhaps, on their ability to grow. So therefore, when we talk about using steroids in children, we, in the back our mind, think about, "Okay, if I use it in the short-term, am I going to be willing to not partner or bridge steroids with another form of therapy that will enable me as a physician treating a patient to feel comfortable that I'm inducing a patient in remission? I'm not thinking about using steroids for maintenance of remission, but I'm thinking of partnering it up with a more long-term maintenance therapy like our immunomodulators, such as 6-mercaptopurine and azathioprine."

The reason being is that we know from some data that, realistically, after twelve months a third of patients are dependent on steroids. This again has been done in the adult population, but because I don't see treatment responsiveness being any different in the pediatric population, I'd say that likely ? to 40% of children would also be dependent on steroids if we let them be-meaning, they responded, but they needed steroids to maintain themselves in remission. That is isolated therapy, not using it with other therapies. Another 20 to 25% of patients will stop responding to steroids. So you're left with the majority of patients either being dependent or no longer responding to these therapies that we know, after a year, has certainly some side effect profiles.

Perhaps even more importantly, in a teenager who's already going through changes with puberty, such as weight change, acne, both of those are significantly seen both short-term and long-term with steroids. So we really need to focus on the psychological impact of these drugs as well, not just on what their effect on bones. But also what this does to a child who's going through puberty, who already has experiences with weight gain and facial acne and skin changes, things that we really need to focus on.

So I think if you think about steroids as a short-term gain, but recognizing that we don't use them for long-term maintenance. And to recognize as physicians that we'd be doing a disservice to our children if we in anyway suggest that, "Okay, well, then if they relapse, we'll just give them another dose and wean them down again." And if they relapse, because then you're talking about over a twelve-month period, patients were on steroids a total of eight to nine months out of that twelve months.

So you're talking, again, about a patient population that needs the most efficacious yet safe medications during this very dynamic phase of growth, both psychologically and physically.