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Ann Rheum Dis. 2019 Jun;78(6):736-745. doi: 10.1136/annrheumdis-2019-215089. Epub 2019 Mar 29.

2019 update of the EULAR recommendations for the management of systemic lupus erythematosus.

Author information

1
Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece afanour@med.uoa.gr.
2
Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece.
3
Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy.
4
Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Dresden, Germany.
5
Department of Pathology, Leiden University Medical Center, Leiden, Netherlands.
6
Nephrology Department and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
7
Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain.
8
Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy.
9
Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.
10
Department of Medical Sciences, Section of Rheumatology, University of Ferrara, Azienda Ospedaliero-Universitaria Sant'Anna Ferrara, Ferrara, Italy.
11
Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium.
12
Department of Medicine, Addenbrooke's Hospital, Cambridge, UK.
13
Cyprus League Against Rheumatism, Aglantzia, Cyprus.
14
University Hospital Muenster, Muenster, Germany.
15
Copenhagen Lupus and Vasculitis Clinic, Rheumatology and Spine Diseases Centre, Rigshospitalet, Copenhagen, Copenhagen, Denmark.
16
Lupus Europe, Farum, Denmark.
17
Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
18
Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
19
Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany.
20
Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria.
21
Department of Medicine, Rheumatology Unit, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.
22
Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic.
23
Rheumatology and Clinical Immunology, University of Brescia, Brescia, Italy.
24
Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark.
25
Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers, Amsterdam, Netherlands.
26
Department of Dermatology and Allergy, University Hospital Bonn, Bonn, Germany.
27
Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece.
28
Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece.
29
Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.
30
Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, Athens, Greece and Medical School, University of Cyprus, Nicosia, Cyprus.
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Contributed equally

Abstract

Our objective was to update the EULAR recommendations for the management of systemic lupus erythematosus (SLE), based on emerging new evidence. We performed a systematic literature review (01/2007-12/2017), followed by modified Delphi method, to form questions, elicit expert opinions and reach consensus. Treatment in SLE aims at remission or low disease activity and prevention of flares. Hydroxychloroquine is recommended in all patients with lupus, at a dose not exceeding 5 mg/kg real body weight. During chronic maintenance treatment, glucocorticoids (GC) should be minimised to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn. Appropriate initiation of immunomodulatory agents (methotrexate, azathioprine, mycophenolate) can expedite the tapering/discontinuation of GC. In persistently active or flaring extrarenal disease, add-on belimumab should be considered; rituximab (RTX) may be considered in organ-threatening, refractory disease. Updated specific recommendations are also provided for cutaneous, neuropsychiatric, haematological and renal disease. Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion.

KEYWORDS:

lupus nephritis; systemic lupus erythematosus; treatment

Conflict of interest statement

Competing interests: AF reports personal fees from GSK, Abbvie, Amgen, Enorasis and Genesis Pharma, outside the submitted work. MA reports fees from advisory boards from Novartis, Pfizer, Roche. IB reports personal fees from consultant for GSK, outside the submitted work. JNB reports grants from GSK, personal fees from GSK, personal fees from Abbvie, personal fees from UCB, personal fees from Enorasis, grants from Pfizer, outside the submitted work. RC reports personal fees from GSK, personal fees from Astra Zeneca, personal fees from Rubió, outside the submitted work. DJ reports personal fees from Astra-Zeneca, Aurinia, Boehringer-Ingeleheim, Celgene, BMS, Chemocentryx, grants and personal fees from GSK, from null, outside the submitted work. AK reports grants from Biogen, grants from Galderma, grants from GlaxoSmithKline, grants from Leo Pharma, personal fees from La Roche Posay, outside the submitted work. MM reports personal fees from GSK, Lilly and UCB. MS reports grants from GSK, UCB, Abbvie, outside the submitted work. JSS reports grants from AbbVie, Astra-Zeneca, Janssen, Lilly, MSD, Novartis, Pfizer and Roche, and personal fees from AbbVie, Amgen, Astra-Zeneca, Astro, BMS, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, MSD, Novartis-Sandoz, Pfizer, Roche, Samsung, Sanofi and UCB, during the conduct of the study. AT reports personal fees from UCB, Pfizer, Abbvie, BMS, Sanofi, Roche, GSK, Alpha Sigma, Lilly, Jannsen, Cellgene and Novartis, outside the submitted work. RvV reports grants from BMS, GSK, Lilly, Pfizer, UCB Pharma, personal fees from AbbVie, AstraZeneca, Biotest, Celgene, GSK, Janssen, Lilly, Novartis, Pfizer, Servier, UCB, outside the submitted work. JW reports grants from GSK, grants from Incyte, personal fees from Biogen, personal fees from Leo, other from Novartis, during the conduct of the study. GB reports grants from GSK, Pfizer and personal fees from GSK, Abbvie, UCB and Enorasis, outside the submitted work. DTB reports unrestricted grant support/advisory board fees from Abbvie, BMS, Celgene, Enorasis, GSK, Pfizer, Novartis, UCB, Lilly, all deposited to the research account of the National and Kapodistrian University of Athens.

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