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


Rheumatology. 2018;57(1):e1-e45. 

In This Article

Rigor of Development

Selection of Questions for the Literature Review, and Statement of Extent of Previous National Institute for Health and Care Excellence, Royal College of Physicians, and Scottish Intercollegiate Guidelines Network guidelines

A multidisciplinary guideline development group was formed and followed the BSR Protocol for Guidelines and EULAR standardized operating procedures to define the focus of the work, the target population and the target audience. Discussions were supplemented by consensus-building strategies, including a modified Delphi technique, in order to reduce and clearly define the list of research questions to be addressed by the literature search (see supplementary data section Search strategy, available at Rheumatology Online). There are no BSR, Royal College of Physicians (RCP), National Institute for Health and Care Excellence (NICE) or Scottish Intercollegiate Guidelines Network (SIGN) guidelines or recommendations for the management of lupus in the UK to help improve the outcome of this variable and potentially life-threatening disease, but lupus has been included in the on-line resource Map of Medicine.

Literature Review: Eligibility Criteria and Limitations of the Search

A systematic search of MEDLINE (PubMed) and the Cochrane Database of Systematic Reviews was performed, and all publications in peer-reviewed English language journals up to June 2015 were considered. A detailed search was performed using an array of relevant terms (see supplementary data section Search strategy and Supplementary Table S1, available at Rheumatology Online), and papers were screened for eligibility based on their title, abstract and/or full content. Studies were eligible if they had studied at least 50 patients for prevalence and prognosis of manifestations, 10 patients for diagnosis and monitoring, or 5 patients for therapy.

Studies on animals, children, review articles, commentaries, conference abstracts or statements, and expert opinion statements were excluded. Narrative review articles and existing guidelines were checked for references, but only meta-analyses and systematic reviews were included, together with original research articles, in the analysis. Over 8000 articles were identified during the literature search, and over 600 were deemed eligible for detailed review by at least two members of the group. There was considerable overlap in the topics covered by the papers, which were reviewed by various members of the group.

Development of the Guideline: Levels of Evidence and Consensus Agreement

The recommendations were developed in line with the BSR's Guidelines Protocol, using RCP, SIGN and AGREE II methodology to assess the level of evidence (LOE) and grade of recommendation (GOR). Papers selected for review and the evidence obtained from them were categorized by at least two members of the group, according to the study design, using the SIGN methodology (Supplementary Table S2, available at Rheumatology Online), and the level of the evidence was graded by combining information on the design and validity of the available research studies to provide the GOR for each component of each statement. The results of the literature search were summarized, aggregated and distributed to the expert committee by three of us (C.G., M.G., M.A.), and the GOR for each item was ratified by the expert committee. Draft recommendations were discussed and rephrased at a face-to-face meeting and subsequently by email, following an updated literature review. The LOEs and the GORs for the data supporting the guideline recommendations are shown in Table 1 and Table 2. Finally, the six recommendations for the management of SLE and the main items in the EULAR/ERA-EDTA recommendations for LN[24] (Table 3) were voted on by clinical members of the guideline development group. For each recommendation, the SOA of all clinical members of the group was sought on a scale of 1 (no agreement) to 10 (complete agreement); the mean percentage agreement was calculated and is shown after each recommendation (all >90% and supported by other members of the group). The guideline will be reviewed in 5 years' time.