British Society for Rheumatology guideline on the management of SLE

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Takeaway

  • First UK-based guidelines for the diagnosis and management of systemic lupus erythematosus (SLE).

Why this matters

  • SLE affects nearly 1 in 1000 people in the United Kingdom. 

Key recommendations

  • Antiphospholipid antibodies (aPLs) should be tested in all patients at baseline. 
  • Confirmatory tests for antiphospholipid syndrome (APS) are positive lupus anticoagulants, anti-cardiolipin antibody and/or anti-beta-2 glycoprotein-1 on 2 occasions ≥12 wk apart. 
  • Patients with active disease should be reviewed at least every 1-3 mo. 
  • Patients with low disease activity or in remission can be reviewed every 6-12 mo. 
  • Presence of aPLs in previously negative patients warrants re-evaluation prior to pregnancy or surgery, or in the presence of new severe manifestation or vascular event. 
  • Check anti-Ro and anti-La antibodies prior to pregnancy. 
  • Treatment of mild disease includes hydroxychloroquine (Plaquenil, Quinoric) and methotrexate (Ebetrex, Maxtrex, Metoject), and short courses of NSAIDs for symptom control. 
  • Prednisolone ≤7.5 mg/d may be required for maintenance.
  • Prednisolone ≤0.5 mg/kg/d or intramuscular/intravenous methylprednisolone for moderate disease. 
  • Consider methotrexate, azathioprine (Imuran), mycophenolate mofetil (Cellcept), ciclosporin (Neoral, Sandimmun Deximune), and other calcineurin inhibitors for arthritis, cutaneous disease, serositis, vasculitis or cytopenias if hydroxychloroquine is insufficient. 
  • For refractory cases, belimumab (Benlysta) or rituximab (Truxima, MabThera) may be considered. 
  • Patients with severe SLE should receive immunosuppression and/or anticoagulation. 
  • Mycophenolate mofetil or ciclosporin for lupus nephritis and refractory, severe non-renal disease. 
  • Consider belimumab where immunosuppressives fail or are poorly tolerated. 
  • Consider intravenous immunoglobulin and plasmapheresis for refractory cytopenias, thrombotic thrombocytopenic purpura, rapidly deteriorating acute confusional state and catastrophic APS.