New systemic lupus erythematosus treatment guidelines break down advice for individual manifestations.
Broadening hydroxychloroquine and biologic immunosuppressive therapies are in, while glucocorticoids are out for patients with SLE, according to the ACR.
The American College of Rheumatology has released its updated guidelines for the treatment of systemic lupus erythematosus, after they featured in a presentation at the recently concluded ACR Convergence in Chicago.
Professor Lisa Sammaritano, lead author on the new guidelines, said the document aimed to highlight treatment recommendations for both children and adults with SLE that would help achieve and maintain remission or a lower level of disease activity, reduce morbidity and mortality and minimise the rate of treatment-related toxicities.
“The major updates include universal use of hydroxychloroquine, minimising glucocorticoid exposure to ≤ 5mg prednisone daily and earlier introduction of conventional and/or biologic immunosuppressive therapies. We also emphasize the role of shared decision-making between clinicians and patients, because multiple factors may impact choice of therapy,” the professor of clinical medicine at Weill Cornell Medicine said.
The guideline has not changed since it was presented in January 2024 when the ACR opened a call for public comment but offers more detailed insight into the rationale and nuances behind each of the recommendations and treatment decisions.
Hydroxychloroquine was preferred over other antimalarials due to its better safety profile, with the guidelines recommending it be used for routine treatment (unless otherwise indicated), and that its use be continued indefinitely, even if sustained remission is achieved.
“A maintenance goal of ≤ 5mg/kg/day is endorsed to minimise long-term toxicity,” the guideline reads.
“Higher does (between 5 and 6.5mg/kg/day) may be justified for shorter term use, i.e., when initiating therapy, addressing periods of incomplete disease control or during pregnancy. [However], the recommendation for indefinite use of HCQ is conditional; further research is needed to determine benefits versus harms.”
The recommendation to minimise glucocorticoid exposure as quickly as possible came from the risk of side effects leading to significant toxicity.
“Tapering off glucocorticoids completely (with addition of immunosuppressive therapy when unable to do so) is recommended because even low-dose long-term glucocorticoid confers risk,” the authors wrote.
Related
“The recommendation to taper off completely is conditional due to because the balance of benefit and harm will vary depending on individual risks as well as personal preferences,” the authors wrote.
Other recommendations included in the guideline address areas relating to monitoring SLE, comorbidities and risk management and organ-specific, haematological and neuropsychiatric manifestations.
All bar two of the recommendations were positive, with the voting panel conditionally recommending against the use of immunosuppressive therapy in patients with asymptomatic neutropenia and/or lymphopenia where no other lupus disease activity is present, and against adding immunosuppressive therapy to cognitive therapy in instances of isolated cognitive dysfunction attributed to SLE.
The authorship team adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology while reviewing the available evidence that informed each of the recommendations. A 70% consensus was required among the voting panel to determine the direction (for/against) and the strength (strong/conditional) of each recommendation.
The new guideline has also been published in Arthritis & Rheumatology.
