Updated EULAR guidelines for lupus management issued
medwireNews: EULAR has published up-to-date recommendations for the management of systemic lupus erythematosus (SLE) based on emerging evidence and expert opinion.
Since the original guidelines were published in 2008, followed by subsequent publication of specific recommendations for neuropsychiatric and renal disease, monitoring, and women’s health, “new data have emerged on treatment strategies and validated goals of treatment, alternative regimens of glucocorticoids (GC), ‘multitargeted’ therapy with the use of calcineurin inhibitors (CNIs) in lupus nephritis (LN), and the approval of the first biological therapy for SLE,” say the guideline authors.
Antonis Fanouriakis (Attikon University Hospital, Athens, Greece) and colleagues carried out a systematic literature review and used Delphi-based methodology to select research questions, elicit expert opinions, and form consensus guidelines, which comprised four overarching principles and 33 recommendations.
As reported in the Annals of the Rheumatic Diseases, the main principles state that SLE is a multisystem disease diagnosed on a clinical basis in the presence of indicative serologic abnormalities, and that care is multidisciplinary, based on shared-decision making between patients and healthcare providers.
Fanouriakis and colleagues recommend that organ- or life-threatening SLE should be treated with high-intensity immunosuppressive therapy to reduce disease activity, followed by a lower-intensity period to prevent relapses, and that overall treatment goals should include “long-term patient survival, prevention of organ damage and optimisation of health-related quality of life.”
In their specific recommendations, the authors say that SLE treatment should aim for remission or low disease activity in all organs, while using the minimum possible dose of glucocorticoids. They add that flares should be treated by increasing the dose of current therapy, switching to another agent, or adding further treatment.
Regarding therapeutic options, the taskforce recommends hydroxychloroquine for all suitable patients, with regular monitoring for retinal toxicity, and specifies that glucocorticoids can be used for active disease, with a maximum dose below 7.5 mg/day prednisone equivalent for maintenance treatment. They say that immunosuppressive agents including methotrexate, azathioprine, and mycophenolate can be used to reduce steroid use, and that belimumab or rituximab can be used when conventional drugs do not give rise to sufficient disease control.
The experts also provide guidance for treating specific manifestations of SLE, including skin, neuropsychiatric, hematologic, and renal disease. They point out that SLE patients are at risk for comorbidities such as antiphospholipid syndrome, infections, and cardiovascular disease, and recommend assessment of these comorbidities, as well as preventive strategies.
Finally, Fanouriakis and team provide recommendations for future research, which they say “aim to improve the design of clinical studies in order to answer clinically important questions, for which the current ‘state-of-the- art’ is insufficient.”
They add that “data regarding the optimal duration and timing of discontinuation of therapy in both renal and extrarenal disease are scarce.”
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