The British Society for Rheumatology Guideline for the Management of Systemic Lupus Erythematosus in Adults

Caroline Gordon; Maame-Boatemaa Amissah-Arthur; Mary Gayed; Sue Brown; Ian N. Bruce; David D'Cruz; Benjamin Empson; Bridget Griffiths; David Jayne; Munther Khamashta; Liz Lightstone; Peter Norton; Yvonne Norton; Karen Schreiber; David Isenberg

Disclosures

Rheumatology. 2018;57(1):e1-e45. 

In This Article

Applicability and Utility

Implementation

Diagnosis and assessment of lupus can be difficult due to multisystem involvement and variable laboratory and serological test results. These guidelines will increase knowledge and raise the standard of care for patients with lupus. Only HCQ, CSs and belimumab are licensed treatments for lupus. The evidence for the treatment options discussed in this guideline, which reflect current best practice, has increased considerably in the last 10 years, although there is still relatively little evidence from high-quality RCTs. There should be no barriers to implementation, apart from limitations on the funding for rituximab and belimumab discussed in the relevant sections. The guidelines will be widely presented at local, regional and national meetings for health professionals and patients, carers and supporters of relevant charities.

Key Standards of Care

Lupus patients should be referred to a physician with experience in managing lupus who can confirm the diagnosis, assess the level of disease activity and provide advice on treatment and monitoring of the disease, its complications and side effects of therapy. Managing immunosuppressive therapies and their potential toxicities in patients with lupus can be a considerable challenge due to the risk of infection, difficulties with attribution of cytopenias to lupus or cytotoxic drugs, and difficulties in distinguishing manifestations of lupus disease activity from damage and co-morbid conditions. Input from a multidisciplinary team including nurse specialists and physiotherapists is usually required, and management may involve a variety of specialists, including rheumatologists, nephrologists, dermatologists, haematologists, cardiologists, chest physicians, neurologists, obstetricians, podiatrists and occupational therapists working as part of collaborative clinical networks involving regional specialist centres, local hospitals and GPs.

It is important to get patients to a low level of disease activity, if not remission, using HCQ, immunosuppressants and the least amount of CSs possible, in order to reduce cumulative damage from the disease and its treatment with CSs.[71] If drug treatment is not working within the expected time frame, it is important to consider adherence to treatment and adjusting the therapy to reduce the accumulation of chronic damage.

Patients need personalized advice, written information and education about the disease and its drug treatment from members of the multidisciplinary team, including specialist nurses and an individual to contact in the event of new symptoms. Additional topics covered should include sun avoidance, adequate vitamin D intake, weight control, exercise, not smoking and other measures to reduce atherosclerotic risk factors, as well as cancer screening, contraception and pregnancy planning when the disease is under good control on appropriate treatment for conception.

Future Research Agenda

There is a need for more evidence to support decision-making in the management of lupus patients. The guideline development group identified certain priorities for research into lupus to help address this issue, and these are shown in Table 8.

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