Clinical Practice Guidelines and Recommendations for the Management of Patients With Systemic Lupus Erythematosus

A Critical Comparison

Margarida Oliveira; Sergio Palacios-Fernandez; Ricard Cervera; Gerard Espinosa


Rheumatology. 2020;59(12):3690-3699. 

In This Article

Abstract and Introduction


Objective: SLE has a great clinical heterogeneity and low prevalence, thus making the development of recommendations or clinical practice guidelines (CPG) based on high-quality evidence difficult. In the last few years, several CPG appeared addressing the management of the disease. The aim of this review is to critically compare the recommendations made in the most recent CPG and to analyse and compare their methodological quality.

Methods: The Appraisal of Guidelines for Research and Evaluation (AGREE) II tool was used to compare the methodological quality of each of the CPG.

Results: Most CPG agreed in the general management and first-line treatment recommendations where there is higher quality evidence and disagreed in refractory disease treatment where there is lack of quality evidence. Also, the CPG are agreed in whether a patient should be treated regarding the most severe clinical manifestation or taking into account the treatment that best serves all clinical manifestations. The majority of the appraised CPG scored high-quality ratings, especially for scope and purpose and clarity of presentation, while they were of less quality when assessing applicability of each CPG.

Conclusion: CPG should aid, but not replace, the health professional's clinical judgment in daily clinical patient management.


SLE is a multiorgan autoimmune disease characterized by a great heterogeneity of clinical manifestations. It is considered an infrequent disease and there is wide geographical variation in the reported incidence and prevalence.[1]

The management of SLE has several objectives: to avoid the appearance of flares, to reduce the chronic activity of the disease, and to avoid the damage accrual produced by the disease and the treatments used.[2] In the majority of cases, managing SLE will require immunosuppressive drugs, with potential toxicity and adverse effects that contribute to damage accrual. In addition, in recent years, targeted biologic therapies are being developed, which entail a high cost for healthcare systems as well as potential toxicity.[3]

The great heterogeneity of clinical manifestations and prognosis of SLE, its low prevalence, and the difficulty in the development of new targeted molecules are obstacles to the development of recommendations or clinical practice guidelines (CPG) based on the best quality evidence. Apart from lupus nephropathy, there is a lack of high-quality evidence regarding the therapeutic management of the majority of SLE clinical manifestations or the efficacy of some classic treatments such as glucocorticoids[4] and other non-biological immunosuppressive agents.[5] In fact, most treatments are widely used based on evidence only from observational studies or on the clinical experience of attending physicians.

For all these reasons, up to the beginning of the present decade there were only few CPG concerning the general management of SLE,[6,7] but mainly focused on the areas where evidence was of best quality, i.e. the treatment of lupus nephritis.[8] However, in the last few years, several CPG from national[9–11] and international societies or multidisciplinary study groups[12,13] appeared addressing the management of the disease in a global way. The aims of the present study were to critically compare the recommendations of each of the most recent CPG, as well as to analyse and compare their methodological quality.