All patients with lupus should receive hydroxychloroquine and, during chronic maintenance treatment, glucocorticoids should be minimized and withdrawn when possible, according to a 2019 update to the EULAR recommendations for the management of systemic lupus erythematosus.
“The first set of the EULAR recommendations for the management of SLE were published in 2008,” Antonis Fanouriakis, MD, of Attikon University Hospital in Greece, told Healio Rheumatology. “Over the past decade, and despite the subsequent publication of recommendations for specific aspects of the disease (monitoring, renal and neuropsychiatric disease, pregnancy and family planning), emergence of new data regarding treatment strategies and goals of treatment, alternative regimens of existing drugs and approval of new ones, called for an update of the recommendations for the general management of lupus.”
“Our methodology followed the standardized operating procedures of EULAR and combined an extensive systematic literature review and expert opinion,” he added. “At the same time, the recommendations were formulated with the purpose to provide practical guidance to physicians caring after patients with this challenging disease.”
All patients with lupus should receive hydroxychloroquine and glucocorticoids should be minimized and withdrawn when possible, according to updated EULAR recommendations.
To update EULAR’s recommendations for SLE management, Fanouriakis and colleagues gathered information and data using a systematic literature review of articles published from January 2007 through December 2017. The search was limited to English-language publications. Employing a modified Delphi methodology, the researchers selected 14 research questions for the review. Studies and evidence that had informed the initial 2008 recommendation were also included.
The resulting data were then categorized based on the design and validity of the available studies. The researchers participated in rounds of discussion to develop a series of statements and overarching principles; each researcher on the task force then rated their agreement with each statement.
The researchers ultimately reached a consensus on 33 final statements each grouped into four categories — goals of treatment, treatment of SLE, specific manifestations and comorbidities. According to the updated recommendations, all patients with lupus should be treated with hydroxychloroquine at a dose not exceeding 5 mg/kg of real body weight. In addition, glucocorticoids should be minimized to less than 7.5 mg per day during chronic maintenance treatment, and eventually discontinued whenever possible. Withdrawing or tapering glucocorticoids can be facilitated through the appropriate use of immunomodulatory agents, such as methotrexate, azathioprine or mycophenolate.
In cases of persistently active or flaring extrarenal SLE, EULAR recommends that providers consider belimumab (Benlysta, GlaxoSmithKline). Providers may consider rituximab (Rituxan, Genentech) in cases of organ threatening or refractory SLE. The recommendations also include information on cutaneous, neuropsychiatric and hematological manifestations of SLE, as well as renal disease. In addition, the task force urges that patients with SLE should be assessed for antiphospholipid antibody status, as well as infectious and cardiovascular diseases risk.
“SLE represents a challenge for the treating physician in terms of diagnosis and treatment,” Fanouriakis and colleagues wrote in the Annals of the Rheumatic Diseases. “Its protean manifestations, often multisystem but occasionally limited to a few or single organ, have led some physicians to focus exclusively on evidence of serological autoimmunity (antinuclear and more specific autoantibodies), for a disease where diagnosis is clinical after excluding competing diagnoses. Monitoring of SLE through validated disease activity and chronicity indices, including physician global assessment, is recommended.”
“For patients with severe disease, multidisciplinary care in dedicated lupus centers is desirable,” they added. “Immunosuppressive therapy (for induction and maintenance of remission) is indicated in organ-threatening lupus.” – by Jason Laday
Disclosures : Fanouriakis reports personal fees from AbbVie, Amgen, Enorasis, Genesis Pharma and GlaxoSmithKline. Please see the full study for additional author disclosures.