Management of systemic lupus erythematosus: a systematic literature review informing the 2023 update of the EULAR recommendations.
The systematic literature review informing the 2023 EULAR update found high-quality randomized evidence supporting anifrolumab in non-renal lupus and belimumab and voclosporin in lupus nephritis, and confirmed that attaining remission or low disease activity improves long-term outcomes.
Background
This systematic literature review analyzed new evidence published between 2018 and 2022 to inform the 2023 update of the EULAR recommendations for the management of systemic lupus erythematosus (SLE). Following EULAR standard operating procedures, searches of Medline and the Cochrane Library addressed five domains, including the benefit and harm of treatments, the value of attaining remission or low disease activity, treatment tapering and withdrawal, management of SLE with antiphospholipid syndrome, and immunization safety.
Key recommendations
The review identified 439 relevant articles, the majority being observational studies of low or moderate quality. High-quality randomized controlled trials documented the efficacy of the type 1 interferon receptor inhibitor anifrolumab in non-renal SLE, and of belimumab and the novel calcineurin inhibitor voclosporin in lupus nephritis, when compared with standard of care. For organ manifestations outside lupus nephritis, high-quality data were lacking, and treatment recommendations relied more heavily on observational evidence and expert opinion.
Clinical implications
Multiple observational studies confirmed that attaining clinical remission or low disease activity reduces the risk of adverse outcomes and is associated with favorable long-term prognosis. Two randomized trials found higher relapse rates in patients who discontinued glucocorticoids or immunosuppressants, yet cohort data suggest gradual tapering may be feasible in a subset of patients once treatment targets are achieved. Combination therapy with belimumab and voclosporin attained higher response rates in lupus nephritis trials.
Category
Guidelines
Source
Ann Rheum Dis
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