2023 Version Of EULAR Lupus Management Recommendations Quick Overview, Hormone Maintenance Dose Reduced To ≤5mg/d

Systemic lupus erythematosus (SLE) is one of the most common connective tissue diseases in the Department of Rheumatology and Immunology. The clinical manifestations, course, and prognosis of patients vary widely. In 2008, the European League Against Rheumatism (EULAR) first formulated SLE management guidelines and updated the recommendations in 2019 with the emergence of new needs and new data in the SLE field. At the 2023 EULAR annual meeting, Professor Dimitrios Boumpas, deputy editor-in-chief of EULAR's official magazine "Annals of Rheumatic Diseases", shared the latest version of SLE management recommendations in 2023, including 5 general principles and 13 specific recommendations. This article is organized as follows.

Click to cistanche tubulosa extract for kidney disease

Highlights of the 2023 Lupus Management Recommendations

Early diagnosis and treatment are crucial.

Glucocorticoids can save lives but at the same time cause too many side effects.

The short-term use of glucocorticoids as bridging therapy is better, but some patients may need long-term use, and the recommended dose is ≤5 mg/kg/d (prednisone as an example) rather than ≤7.5 mg/d.

The goal of treatment can be remission or low lupus disease activity (LLDAS), but the dose of glucocorticoids should be ≤5 mg/d (prednisone as an example).

Biologics can help reduce the dose of glucocorticoids while helping patients achieve remission of LLDAS and reduce relapses and lesions.

General principle

A. SLE requires multidisciplinary, individualized management based on patient education and shared decision-making, taking into account individual and societal costs.

B. SLE disease activity should be assessed at each visit (frequency is at the discretion of the physician) and visceral damage should be assessed (at least annually) using validated tests.

C. Nonpharmacologic interventions, including sun protection, smoking cessation, a healthy balanced diet, regular exercise, and measures to promote bone health, are important to improve long-term patient outcomes.

D. Drug intervention should be guided by patient characteristics, type and severity of organ involvement, treatment-related harms, comorbidities, risk of progressive organ damage, and patient preference.

E. Early diagnosis of SLE (including serological assessment), regular screening for visceral involvement (especially nephritis), timely initiation of treatment to achieve remission (or at least reduction of disease activity), and strict adherence to treatment are important for preventing recurrence and visceral involvement. damage, improved prognosis, and improved quality of life are critical.

13 suggestions

➤Recommendation 1: Unless there are contraindications, hydroxychloroquine is recommended for all SLE patients (1b/A), the target dose is 5mg/kg/d according to the actual body weight (2b/B), but it should be based on the recurrence risk (2b/B) and Retinal toxicity was adjusted individually.

➤Recommendation 2: The dose of glucocorticoid (GC) should be determined according to the type and severity of organ involvement (2b/C), and the maintenance dose should be reduced to 5 mg/d (taking prednisone as an example) (2a/ B), and discontinue the drug if possible; for patients with moderate to severe disease, intravenous methylprednisolone pulse therapy (125-1000 mg per day for 1-3 days) may be considered (3b/C).

➤ Recommendation 3: For patients who do not respond to hydroxychloroquine (alone or in combination with GC), or who cannot reduce GC below the maintenance dose, the addition of an immunomodulator/immunosuppressant (such as methotrexate [1b/B ], azathioprine [2b/C] or mycophenolate mofetil (2a/B)), and/or biologics (eg, belimumab [1a/A] or nivolumab [1a/A]).

➤Recommendation 4: Intravenous cyclophosphamide (2b/C) should be considered for patients with organ or life-threatening conditions; in refractory cases, rituximab (2b/C) can be considered.

➤ Recommendation 5: The treatment regimen for active skin disease in SLE should include topical agents (GC, calcineurin inhibitors) (2b/B), antimalarials (hydroxychloroquine, chloroquine) (1a/A), and/or the systemic application of GC (4/C), methotrexate (1b/B), mycophenolate mofetil (4/C), anifrolumab (1a/A) or belimumab (1a/B) can be used as second-line therapy.

➤ Recommendation 6: Treatment of active neuropsychiatric lupus should include GC and immunosuppressants for inflammation-related manifestations (1b/A) and antiplatelet agents/anticoagulants for atherothrombosis/antiphospholipid antibody-related manifestations Treatment (2b/C).

➤Recommendation 7: For acute treatment of severe autoimmune thrombocytopenia: high-dose GC (including intravenous methylprednisolone pulse therapy) (4/C), with or without intravenous immunoglobulin G (4/C ), and/or rituximab (2b/B), and/or high-dose intravenous cyclophosphamide (4/C), rituximab (2b/B), azathioprine ( 2b/C), mycophenolate mofetil (2b/C), or cyclosporine (4/C).

➤ Recommendation 8: Patients with active proliferative lupus nephritis should receive low-dose (EuroLupus) intravenous cyclophosphamide (1a/A) or mycophenolate mofetil (1a/A) combined with GC (intravenous methylprednisolone followed by Oral low-dose GC); the combination of belimumab (in combination with cyclophosphamide or mycophenolate mofetil [1b/A]) or a calcineurin inhibitor (particularly voclosporin or tacromol combination with mycophenolate mofetil, 1b/A).

➤ Recommendation 9: After the renal response, treatment of lupus nephritis should be continued for at least 3 years (2b/B); initially use mycophenolate mofetil alone or in combination with belimumab or a calcineurin inhibitor Patients treated with other agents should continue with these agents (1a/A), while patients initially treated with cyclophosphamide alone (1a/A) or in combination with belimumab (1a/A) should be treated with mecomolecox Phenyl esters or azathioprine instead of cyclophosphamide.

➤ Recommendation 10: For patients at high risk for renal failure (defined as reduced glomerular filtration rate, presence of fibrous crescents, fibrinous necrosis, glomerular atrophy/interstitial fibrosis), high doses may be considered (NIH protocol) Intravenous cyclophosphamide (1a/A) combined with intravenous methylprednisolone pulse therapy.

➤ Recommendation 11: In SLE patients who achieve sustained remission, tapering therapy should be considered, with GC discontinued first (2a/B).

➤ Recommendation 12: For patients with thrombotic antiphospholipid syndrome (APS), after the first arterial or unprovoked venous thrombotic event (1b/B), vitamin K antagonists should be taken long-term; low-dose aspirin (75-100 mg/day) can be used as primary prevention in SLE/non-APS patients with a high-risk antiphospholipid antibody profile (2a/B).

➤ Recommendation 13: Vaccination should be given to prevent infection (HZV, HPV, influenza, COVID-19, and pneumococcus), bone health, renal protection, and cardiovascular risk should be managed, and malignancy should be screened (-/D).