ACR Releases New Guideline for Management of SLE at ACR 2025

For pleuropericarditis, the guideline conditionally recommends initial treatment with non-steroidal anti-inflammatory drugs (NSAIDs), colchicine or their combination, with a low threshold to escalate to glucocorticoids, over initiating with steroids alone.

“Glucocorticoids may still be needed in SLE pericarditis,” Dr. Duarte-Garcia said. “For example, they may have other concomitant systemic disease activity, contraindication to NSAIDs, drug interactions or symptoms unresponsive to NSAIDs and colchicine.”

For ongoing/recurrent pleuropericarditis despite NSAIDs, colchicine and/or glucocorticoids, conventional immunosuppressants or biologic therapies are recommended over initiating or increasing glucocorticoid monotherapy.

“The voting panel’s preferred biologic therapy for predominant pleuropericarditis is IL-1 [interleukin-1] blockade,” Dr. Duarte-Garcia said. “This had low level of evidence but was backed by consensus and experience of the Voting Panel.”

He presented a randomized, controlled trial of azathioprine (AZA) vs. mycophenolic acid analog (MPAA) in 240 patients with SLE of which 70 had serositis. The trial demonstrated no statistically significant difference but trend to MPAA (with numerical benefit of MPAA in serositis compared with AZA).³

Pooled analysis of belimumab trials (BLISS-52 and BLISS-76) demonstrated numerical benefit for belimumab in SLE serositis, although underpowered for significance, Dr. Duarte-Garcia explained.⁴ Similarly, pooled analysis from TULIP-1 and TULIP-2 for anifrolumab favored active drug, although underpowered for significance.⁵ Lastly, a meta-analysis of observational studies and randomized, controlled trials in recurrent pericarditis demonstrated improvement in patients who received IL-1 blockade compared with placebo or standard of care, but patients with SLE were excluded from most of these studies.⁶

Treating Cutaneous Lupus

Dr. Werth

Victoria Werth, MD, professor of dermatology at the University of Pennsylvania and chief of dermatology at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, spoke on the guideline recommendations for cutaneous lupus.

“Skin involvement is present in up to 70–80% of patients with SLE,” Dr. Werth said. “These patients have lower quality of life, and early treatment is critical to minimize damage.”

For sunscreen, the recommendation is to block both UVB and UVA, with SPF 70 or higher recommended for chemical sunscreens and SPF 50 or higher for physical-based sunscreens, Dr. Werth reviewed.

The cutaneous lupus erythematosus (CLE) category combines acute, subacute and chronic cutaneous lupus erythematosus. Initial therapy for cutaneous lupus rash includes hydroxychloroquine, topical glucocorticoids and/or calcineurin inhibitors, and intralesional steroids and/or brief course of oral glucocorticoids.

For mild CLE that is ongoing despite treatment with hydroxychloroquine and/or topical therapies, the guideline conditionally recommends adding quinacrine or switching to chloroquine, over adding an immunosuppressive agent. “Quinacrine is available through compounding pharmacies and not associated with increased retinopathy risk,” Dr. Werth noted. “In contrast, chloroquine has a higher risk for retinal toxicity and requires visual fields every four to six months.”