ACR Releases New Guideline for Management of SLE at ACR 2025

For ongoing moderate-severe cutaneous lupus refractory to topical and antimalarial therapies and/or oral glucocorticoid necessitating escalation of therapy, the guideline conditionally recommends the addition of methotrexate (MTX), MPAA, anifrolumab and/or belimumab. “Choice of specific therapy should be based on severity of lesions, the risk for scarring, comorbidities and patient preference,” Dr. Werth said. Given limited data and difference of opinion among panel members, no prioritization of specific agents was made.

For moderate-severe refractory cutaneous lupus that fails all other therapies discussed, the guideline recommends adding or substituting lenalidomide.

For mild ongoing bullous lupus, despite topical and antimalarial therapies, dapsone is recommended over glucocorticoid. For moderate-severe bullous lupus refractory to therapy, a conventional immunosuppressive (MPAA, methotrexate, azathioprine) and/or anti-CD20 therapy is recommended.

For chilblain lupus, despite topical and antimalarial therapies, the guideline recommends the addition of pentoxifylline, PDE5 inhibitors (e.g., sildenafil) and/or calcium channel blockers, over immunosuppressive therapies.

For mild cutaneous vasculitis, despite topical and antimalarial therapies, the guideline recommends the addition of dapsone or colchicine over immunosuppressive therapies.

Treating Lupus Arthritis

Dr. Askanase

Anca Askanase, MD, professor of medicine at Columbia University School of Medicine, New York, next presented on applying the guideline to treating arthritis. “Joint involvement occurs in up to 95% of SLE patients,” Dr. Askanase said. “It can result in permanent joint damage or deformity, lower quality of life and work disability.”

For acute or recurrent episodes of inflammatory arthritis, the guideline recommends a course of NSAIDs or limited course of oral glucocorticoids. For patients who have persistent or recurrent active SLE arthritis and are taking HCQ, the guideline recommends initial therapy with MTX, MPAA or AZA, with low threshold to add or substitute with belimumab or anifrolumab for inadequate response, over initial biologic therapy.

Additional conditional recommendations were provided, such as considering initial biologic therapy for refractory arthritis or combination therapy (conventional disease-modifying anti-rheumatic drug plus biologic). For predominant arthritis without other organ involvement, MTX can be considered first. For other organ involvement, MPAA might be preferable. For those planning pregnancy, azathioprine is preferred.

“When arthritis is the predominant feature, leflunomide or other therapies approved for rheumatoid arthritis [RA] could be used,” Dr. Askanase said. “Baricitinib has moderate evidence supporting its benefit. There is also limited evidence supporting benefit for abatacept, tocilizumab, tofacitinib and ustekinumab.”

For Jaccoud arthropathy, no consensus was reached on surgical or medical therapy. Referral to occupational therapy/physical therapy, splinting or bracing were suggested.