GUIDELINES - EULAR recommendations for the management of SLE

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Published Online First: 15 May 2007. doi:10.1136/ard.2007.070367

ls of the Rheumatic Diseases 2008;67:195-205

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EULAR recommendations for the management of systemic lupus erythematosus.

Report of a Task Force of the EULAR Standing Committee for International

Clinical Studies Including Therapeutics

G Bertsias 1, J P A Ioannidis 2, J Boletis 3, S Bombardieri 4, R Cervera 5,

C Dostal 6, J Font 5, I M Gilboe 7, F Houssiau 8, T Huizinga 9, D Isenberg

10, C G M Kallenberg 11, M Khamashta 12, J C Piette 13, M Schneider 14, J

Smolen 15, G Sturfelt 16, A Tincani 17, R van Vollenhoven 18, C Gordon 19, D

T Boumpas 1

1 Internal Medicine, and Rheumatology, Clinical Immunology and Allergy,

University of Crete School of Medicine, Heraklion, Greece

2 Clinical Trials and Evidence-Based Medicine Unit, Department of Hygiene

and Epidemiology, University of Ioannina School of Medicine, Ioannina,

Greece

3 Department of Nephrology and Transplantation Medicine, Laiko Hospital,

Athens, Greece

4 Cattedra di Reumatologia, Universita di Pisa, Pisa, Italy

5 Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain

6 Institute of Rheumatology, Prague, Czech Republic

7 Department of Rheumatology, Rikshospitalet, Oslo, Norway

8 Rheumatology Department, Université catholique de Louvain, Cliniques

Universitaires Saint-Luc, Brussels, Belgium

9 Department of Rheumatology Leiden University Medical Center, Leiden, The

Netherlands

10 Centre for Rheumatology, University College London Hospitals, London, UK

11 Department of Clinical Immunology, University Medical Center Groningen,

Groningen, The Netherlands

12 Lupus Research Unit, The Rayne Institute, St ’ Hospital, London, UK

13 Service de Médecine Interne, Groupe Hospitalier Pitié-Salpêtrière, Paris,

France

14 Rheumatolology, Clinic of Endocrinology, Diabetology and Rheumatology,

Heinrich-Heine-University, Dusseldorf, Germany

15 Department of Rheumatology, Medical University of Vienna, Austria

16 Department of Rheumatology, University Hospital of Lund, Lund, Sweden

17 Rheumatologia e Immunologia Clinica, Ospedale Civile di Brescia, Italy

18 Rheumatology Unit, Department of Medicine, Karolinska Institutet,

Karolinska University Hospital, Solna, Sweden

19 Centre for Immune Regulation, Division of Immunity and Infection, The

University of Birmingham, Birmingham, UK

Objective: Systemic lupus erythematosus (SLE) is a complex disease with

variable presentations, course and prognosis. We sought to develop

evidence-based recommendations addressing the major issues in the management

of SLE.

Methods: The EULAR Task Force on SLE comprised 19 specialists and a clinical

epidemiologist. Key questions for the management of SLE were compiled using

the Delphi technique. A systematic search of PubMed and Cochrane Library

Reports was performed using McMaster/Hedges clinical queries’ strategies for

questions related to the diagnosis, prognosis, monitoring and treatment of

SLE. For neuropsychiatric, pregnancy and antiphospholipid syndrome

questions, the search was conducted using an array of relevant terms.

Evidence was categorised based on sample size and type of design, and the

categories of available evidence were identified for each recommendation.

The strength of recommendation was assessed based on the category of

available evidence, and agreement on the statements was measured across the

19 specialists.

Results: Twelve questions were generated regarding the prognosis, diagnosis,

monitoring and treatment of SLE, including neuropsychiatric SLE, pregnancy,

the antiphospholipid syndrome and lupus nephritis. The evidence to support

each proposition was evaluated and scored. After discussion and votes, the

final recommendations were presented using brief statements. The average

agreement among experts was 8.8 out of 10.

Conclusion: Recommendations for the management of SLE were developed using

an evidence-based approach followed by expert consensus with high level of

agreement among the experts.

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Approximately half a million people in Europe and a quarter of a million

people in the USA (projections based on prevalence rates of 30–50 per 100

000) have systemic lupus erythematosus (SLE).1 The great majority of these

patients are women in their childbearing years. SLE is a complex disease

with variable presentations, course and prognosis characterised by

remissions and flares.2 3 Because of the systemic nature of the disease,

multiple medical specialties are involved in the care of these patients. To

avoid fragmentation and optimise management, there is a presently unmet need

to establish an integrated approach based on widely accepted principles and

evidence-based recommendations.

Recommendations and/or guidelines represent a popular way of integrating

evidence-based medicine to clinical practice. These are systematically

developed statements to assist practitioner and patient decisions about

appropriate healthcare for specific clinical circumstances.4 To this end and

under the auspices of EULAR, we undertook the task of developing guidelines

for the management of various aspects of SLE. To ensure a high level of

intrinsic quality and comparability of this approach, we used the EULAR

standard operating procedures.5 We present here 12 key recommendations,

selected from a panel of experts, for the management (diagnosis, treatment,

monitoring) of SLE using a combination of research-based evidence and expert

consensus.

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http://ard.bmj.com/cgi/content/full/67/2/195

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