EULAR 2023 Recommendations for the Management of Systemic Lupus Erythematosus: One Step Forward

The European Alliance of Associations for Rheumatology (EULAR) recommendations for the management of systemic lupus erythematosus (SLE) have become a 'tradition' since their first publication in 2008, guiding physicians who care after patients with this challenging disease.In their most recent update in 2023, the respective first Task Force was expanded to include, for the first time, renowned lupus experts from four continents, in an effort to reflect practice all around the globe.To facilitate dissemination of the recommendations, the latter were shortened compared to previous versions, counting a total of 13 recommendations.Highlights include further reductions in the recommended maintenance dose of glucocorticoids (GC), a strong recommendation for early use of conventional and biologic immunosuppressive drugs and the use of combination therapies in lupus nephritis (LN). GLUCOCORTICOIDS: ENVISIONING THEIR USE AS BRIDGING THERAPYGC along with hydroxychloroquine remain one of the cornerstones of the treatment of SLE, exerting their effects through genomic and non-genomic pathways.1 Dose and route of administration varies depending on prevailing disease manifestations and their severity.Daily dose is categorised as low (≤ 7.5 mg/day of prednisone-equivalent), medium (7.5-30 mg/day), high (30-100 mg/day) and very high (>100mg), but the latter are almost never used nowadays.2 GC may provide rapid symptom relief, however prolonged treatment is associated with an increased risk for infections, metabolic disturbances such as diabetes mellitus, cardiovascular events, irreversible organ damage and mortality.3,4 To this end, the target is GC minimisation and, if feasible, complete withdrawal.This recommendation is not limited to SLE, but the latter has proven notoriously difficult to be treated with GC-free regimens, and a subset of patients are dependent on GC for symptom control.In the 2019 recommendations, the 'acceptable' threshold of daily prednisone dose for maintenance treatment was ≤ 7.5 mg/day prednisone equivalent 5 ; this was changed to 5 mg/day in the current update, 6 in a statement that received 96.3% agreement and mean (SD) level of agreement 9.57 (0.77).It should be noted that this recommendation was not based on randomised data (as was the case for example in ANCA-associated vasculitides, where two different GC regimens were also tested during the PEXIVAS trial 7 ; rather, observational studies indicate that in a setting of low disease activity, a dose ≤ 5 mg/day prednisone equivalent is associated with lower damage accrual as compared to a dose ≤ 7.5 mg/day.8 To facilitate faster GC tapering, in moderate/severe disease the use of GC pulses (250-1000 mg/day for 1-3 days) should be considered.6 Of note, low dose pulses regimens (1500mg in three days) are equally effective as high dose pulses (3000-5000mg).9 Treatment with pulse GC may be followed by per os prednisone at doses of 0.3-0.5 mg/ Kg/day with tapering; the use of the traditional 1 mg/ kg regimen does not lead to an additional therapeutic benefit, given that the genomic pathway is nearly completely saturated at doses >30mg prednisone-equivalent per day.10