EULAR: Steroids a ‘bridging therapy only’ in lupus
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Steroid sparing with novel agents, including belimumab and voclosporin, is recommended for patients with systemic lupus erythematosus, according to updated guidelines presented at the EULAR 2023 Congress.
“The overarching principles deal with multidisciplinary care,” Dimitrios Boumpas, MD, chair of the European task force on SLE and president of the Athens Medical Society, said of the new EULAR recommendations. “They deal with the need to monitor disease activity and damage.”
Both pharmacologic and non-pharmacologic interventions are covered in the overarching principles, as is the need for early diagnosis to minimize morbidity, prevent damage and flares, and improve quality of life.
“Despite increased awareness, there are still data showing lupus patients face diagnostic delay,” Boumpas said.
The guideline development process followed similar protocols for other EULAR recommendations, including a literature review, task force meetings and a voting process.
The first recommendation statement notes that hydroxychloroquine should be used in the first line at 5 mg/kg, according to Boumpas.
“The target dose remains the same,” he said.
The second statement, meanwhile, contains a new recommendation, which is that 5 mg or less per day of prednisone is preferred for a maintenance dose, compared with 7.5 mg per day from the previous iteration.
“This recommendation pertains both to new onset or relapsing disease of lupus,” Boumpas said. “We use steroids in lupus as a bridging therapy only.”
The third recommendation deals with disease-modifying antirheumatic drugs and biologics as steroid sparing agents. Specifically, the clinician can choose methotrexate, azathioprine, belimumab (Benlysta, GlaxoSmithKline) or anifrolumab (Saphnelo, AstraZeneca).
“It is not necessary to use a DMARD first,” he said, noting that this “allows more flexibility” in prescribing.
For statement four, cyclophosphamide or rituximab (Rituxan, Genentech) may be considered for severe, life-threatening disease.
“It is OK to use cyclophosphamide — it’s not a sin,” Boumpas said.
Another change is seen in the fifth statement, where it is suggested that for skin disease, after methotrexate or hydroxychloroquine, belimumab or anifrolumab may be considered.
An additional key change in the seventh recommendation notes that the “new kid on the block,” mycophenolate mofetil, can be used in a maintenance therapy role, according to Boumpas.
The eighth statement pertains to lupus nephritis. Although mycophenolate mofetil and intravenous cyclophosphamide should be used in these patients, belimumab and voclosporin (Lupkynis, Aurinia Pharmaceuticals) should be considered in all patients with lupus nephritis “from the beginning,” Boumpas said.
“Voclosporin works very fast but you worry about some of the side effects,” he added. “Belimumab is gentle power that sustains response, decreases steroids, prevents flares and decreases organ damage.”
The other big change in the 2023 document pertains to maintenance therapy for lupus nephritis. Patients should be treated for at least 3 years with some combination of mycophenolate mofetil, belimumab, azathioprine or cyclophosphamide.
There are 13 total statements in the updated EULAR lupus recommendations. Boumpas encouraged attendees to review all of the recommendations to stay on the cutting edge of treatment protocols.
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Boumpas D. EULAR-Recommendations on the management of lupus. Presented at: EULAR 2023 Congress; May 31 to June 3, 2023, Milan, Italy.
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