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New Treatment Guidelines for Systemic Lupus Erythematosus for Children and Adults
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Dr. Susan Manzi 0:00
Hello everyone. I'm Dr. Susan Manzi. I am the chair of the Medicine Institute at Allegheny Health Network in Pittsburgh. I also direct our Lupus Center of Excellence and I have the privilege of serving as the Medical Director for the Lupus Foundation of America. And I'm here today to tell you some very exciting news. The American College of Rheumatology has just released the 2025 new guidelines on the treatment of systemic lupus.
We could not be happier to see these guidelines in print for the first time. They're very important guidelines in treatment because the goal is to ensure that no matter what doctor you see anywhere in the country, that you're going to get the best care because we want best practice medicine to ensure you get the care that you deserve. so having guidelines helps physicians know what to do and kind of have the general guidance that we need. Keep in mind though, that decisions are individualized because every person living with lupus is unique. So these are simply guidelines and they don't dictate what medications you have to use at any given time, but they do provide best practice. around the different agents that are now available. And it's very exciting because we have a lot more agents in the pipeline and many more that have been approved for use in the last several years. So what did these guidelines tell us? Well, good news is that they're applicable to not just adults, but also children, which is a great thing because we know that many people living with lupus are young adults or young children.
The other important piece is that when we're treating our patients with lupus, we want people to be in remission. That means no evidence of disease activity. And if we can't get there, then we want the lowest disease activity possible. So that's the goal. And that's what we want to focus on. Not a little bit better, but a lot better. We also are very focused on minimizing side effects and toxicity because as you know, many of the medications that we use, prednisone or corticosteroids is one of them, have a lot of side effects and can actually cause damage to our organs and we want to minimize that. And overall, we just want to improve the quality of life of people living with lupus and improve survival. And these guidelines are set out to do that.
So what are some of the things that were emphasized in these guidelines that are important? One is hydroxychloroquine, right? This is an agent that is an anti-malarial which used frequently in people living with lupus and it's highly recommended for anyone that has lupus and it's a good agent. It's generally well tolerated and it's been known to treat manifestations of the disease but also has evidence of preventing some progression in certain organs that can be involved in lupus. So that is a mainstay for us. A lot of emphasis, as we've seen even in previous guidelines on treatment of kidney disease specifically, is minimizing corticosteroids. They work very quickly, so we need them often to get disease under control quickly, but then the goal is to taper to the lowest dose possible, less than five milligrams a day, or completely off if possible. Because they're effective, but the side effect and risks are too great to try to maintain at any higher dose than five milligrams a day. And as I mentioned, ideally off entirely.
So what do we do if we can't have corticosteroids? Well, now we have a lot of other options. We have some of our conventional immunosuppressive agents that are very, very effective, but we also have a lot of new biologics that are out there. Bulimumab, anaphroleumab, voclosporin, other agents that now are available to us that we can start to use early. And the idea is starting them early and allowing us to get off of corticosteroids. And so some of the guidelines will go through specific treatments for different organ systems, like if your blood counts are impacted or if you've got you know, inflammation around your heart or lungs, they'll provide some guide rails or guard rails around what may be the most effective way to treat it. I won't go into the details of those because again, that's, that's on an individualized basis, but we have a lot more options now. And very importantly, and this is really important, is monitoring, right? We don't want you to be diagnosed with lupus and then get lost to follow up. That regular monitoring is important to make sure nothing new shows up that we need to address early because we want to prevent damage to the organs and we need to measure that on a regular basis to make sure the medication or the disease itself is not causing irreversible damage.
And then finally, even though focusing on your lupus is important, we are also have to focus on your heart health. So preventing any kind of cardiovascular issues, focusing on healthy bones and a lot of that is minimizing steroids to prevent osteoporosis. Also, appropriate cancer screening is important. And then finally, making sure we're preparing you for the best pregnancy outcomes possible if you are of reproductive age. So overall, could not be more excited that these guidelines are now released and I'm sure you'll be hearing a lot more about it. So stay tuned and The Lupus Foundation of America is always a great source for the most important and accurate information.
This week, the American College of Rheumatology (ACR) released updated guidelines for the treatment and management of systemic lupus erythematosus (SLE), the most common form of lupus. The new guidelines aim to reach and preserve remission or low disease activity, reduce organ damage, lower morbidity and mortality rates, and reduce treatment-related side effects and toxicities in people with SLE. The guidelines also place a strong emphasis on shared-decision making and encourage patients and providers to work together to identify treatment preferences. The updated, consensus-based guidelines are applicable to children and adults with SLE.
The guidelines propose:
Broad, routine use of hydroxychloroquine, minimizing glucocorticoid exposure, and timely introduction of standard and/or biologicimmunosuppressive medications(e.g., cyclophosphamide, mycophenolic acid, azathioprine, methotrexate, belimumab, anifrolumab, and anti-CD20 therapies). Selection of these therapies should be individualized based on disease manifestations and the specific organs affected. ACR underscores the role of shared decision-making between people living with SLE and clinicians, as multiple factors impact therapeutic choices.
Regular follow-up appointments to assess lupus disease activity and changes in symptoms with additional annual evaluation for long-term damage caused by lupus.
Aggressive use of high-dose intravenous steroids during severe flares involving vital organs, followed by gradual reduction in oral doses of steroids.
Physician-managed tapering of steroid use to 5 mg daily or lower, ideally stopping within 6 months if lupus is stable.
Additionally, when evidence-based data, clinical expertise, and patient-reported experiences and preferences do not clearly favor one medication over another, therapy recommendations should be presented without a specific order of preference. It is crucial that all treatment decisions are tailored to the individual and involve shared decision-making, which is vital for respecting values and preferences of people with SLE.
The new guidelines acknowledge that there may be challenges in implementing these recommendations due to limited access to testing, specialists, procedures, and medications. If recommended therapies are unavailable, not well-tolerated, or not preferred, discussions about reasonable alternative treatments are encouraged. Collaborative care between rheumatologists and other specialists is also encouraged.
Notably, the revised guidelines can help to address healthcare disparities, which significantly impact outcomes for individuals with SLE. The Lupus Foundation of America has been committed to advancing health equity in lupus by uncovering and addressing the causes of differences in health outcomes across diverse populations living with lupus. Learn more about Lupus AIM (Addressing health Inequities in Minorities).
This announcement marks an important first step towards precision medicine for SLE. The full guidelines will be submitted for publication in Arthritis & Rheumatology and Arthritis Care and Research. The LFA is committed to keeping you updated along the way. As more details become available, we’ll provide you with tools and resources to better understand SLE and the role these guidelines play in helping you achieve optimal outcomes.