EULAR Updates SLE Management Guidelines

The European League Against Rheumatism (EULAR)’s most up-to-date guidelines for managing systemic lupus erythematosus (SLE) were recently featured in Annals of the Rheumatic Diseases.

EULAR’s first SLE management recommendations were released in 2008, but new data have since become available, including “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,” the authors wrote.

According to the guidelines, the goal in SLE treatment is to achieve remission or low disease activity as well as prevent flares in all organs while using the lowest dose of GCs possible. When flares occur, they can be treated based on the severity of the organ or organs involved by increasing therapy doses, or switching or adding new therapies.

Some highlights of the newest guidelines pertaining to treatment include:

  • All SLE patients should take hydroxychloroquine (HCQ) at a dose no greater than 5 mg/kg real body weight
  • Patients under chronic maintenance treatment should not exceed a daily GC dose of 7.5 mg; if possible, GC should be tapered/withdrawn, which can be achieved with the use of immunomodulatory agents such as methotrexate, azathioprine, mycophenolate
  • Add-on belimumab may help patients with active or flaring extrarenal disease, and patients with refractory disease could benefit from rituximab (RTX)

SLE Treatment

The researchers recommend HCQ in all SLE patients, for which there are multiple established benefits and high treatment adherence rates. Long-term HCQ use may come with risks, including retinal toxicity. Retinopathy risk factors include duration of treatment (odds ratio [OR] 4.71 for every five years of use), dose (OR 3.34 for every 100 mg daily dose), chronic kidney disease (adjusted OR 8.56) and pre-existing retinal or macular disease. Among patients who are not at high risk, the researchers recommend that “ophthalmological screening (by visual fields examination and/or spectral domain-optical coherence tomography) should be performed at baseline, after 5 years, and yearly thereafter.”

GC use may help relieve symptoms but should not be a long-term treatment component because it could lead to serious adverse events such as irreversible organ damage. The optimal daily dose should not exceed 7.5 mg/day prednisone equivalent; continuous higher doses significantly increase risks, and some studies have suggested that lower doses may have adverse impacts as well.

For patients who do not benefit from HCQ, the guidelines recommend considering immunomodulating/immunosuppressive agents such as methotrexate, azathioprine, or mycophenolate.

Patients who do not respond to the aforementioned treatment strategies may be considered for add-on belimumab treatment.