The first UK guideline on the care of adults with systemic lupus erythematosus (lupus) was published by the British Society of Rheumatology at the start of October 2017. BSR's 'gold standard' clinical guidelines support evidence-based clinical practice in rheumatology. Patients with lupus should be monitored on a regular basis for disease manifestations, drug toxicity and co-morbidities (LOE 2 ++, GOR B, SOA 99%). Mild disease activity is clinically stable with no life-threatening organ involvement, mainly manifestings as arthritis, mucocutaneous lesions and mild pleuritis. Search for other works by this author on: Royal National Hospital for Rheumatic Diseases, Bath, Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Institute for Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, The Kellgren Centre for Rheumatology, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester, Louise Coote Lupus Unit, Guy’s Hospital, London, Laurie Pike Health Centre, Modality Partnership, Birmingham, Department of Rheumatology, Freeman Hospital, Newcastle upon Tyne, Department of Medicine, University of Cambridge, Lupus and Vasculitis Unit, Addenbrooke’s Hospital, Cambridge, Lupus Research Unit, The Rayne Institute, St Thomas’ Hospital, London, Division of Women’s Health, King’s College London, Section of Renal Medicine and Vascular Inflammation, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, Centre for Rheumatology, University College London, London, UK, for the British Society for Rheumatology Standards, Audit and Guidelines Working Group, The incidence and prevalence of systemic lupus erythematosus in the UK, 1999–2012, Birmingham SLE cohort: outcomes of a large inception cohort followed for up to 21 years, EULAR recommendations for the management of systemic lupus erythematosus. More information on accreditation can be viewed at www.nice.org.uk/accreditation. received funding to attend a scientific meeting from Daiichi Sankyo. The UHB participated in the All Wales BSR Systemic Lupus Erythematosus (SLE) audit and its compliance is above average for most standards for both the Welsh and UK averages. Patients with stable low disease activity or in remission can be monitored less frequently, for example, 6–12 monthly (4/D) (SOA 99%). Confirmatory tests for APS are positive LA, aCL (IgG, IgM) and/or anti-beta-2 glycoprotein-1 (IgG, IgM) on two occasions at least 12 weeks apart (2 ++/B) (SOA 97%). The smallest effective dose of CS should be used. methylprednisolone (2+/C) or high-dose oral prednisolone (up to 1 mg/kg/day) (4/D) to induce remission, either on their own or more often as part of a treatment protocol with another immunosuppressive drug (4/D) (SOA 98%). Those with active disease should be reviewed at least every 1–3 months (2+, C/D), with blood pressure (1+/A), urinalysis (1+/A), renal function (1+/A), anti-dsDNA antibodies (2 ++/B), complement levels (2+/C), CRP (2+/C), full blood count (3/C), and liver function tests (4/D) forming part of the assessment, and further tests as necessary (4/D). To provide comprehensive recommendations, covering the diagnosis, assessment, monitoring and treatment of mild, moderate and severe active lupus disease based on a literature review (to June 2015) for non-renal lupus, supplemented as necessary by UK expert opinion and consensus agreement, and that do not imply a legal obligation. Diagnosing lupus is difficult because signs and symptoms vary considerably from person to person. If the test is negative, there is a low clinical probability of the patient having SLE. For Permissions, please email: journals.permissions@oup.com. The lowest effective dose of prednisolone or other CSs should be used at all times. Higher performance with nephritis screening in dedicated clinics supports wider adoption of this service-delivery mod … Clinical assessment of a lupus patient should include a thorough history and review of systems, full clinical examination and monitoring of vital signs, urinalysis, laboratory tests, assessment of health status and quality of life, and measurement of disease activity and damage using standardized SLE assessment tools (2 ++/B). A descriptive analysis was undertaken of each infusion reaction, which was then assessed using the clinical information available to hypothesise on the possible underlying mechanism(s). Immunosuppressive agents are often required to control active disease and are steroid-sparing agents (2+/C). As mentioned in the 2018 BSR SLE guidelines, postvaccination antibody levels can be measured to assess response.4. If you need to renew your membership or check something related to it, please contact membership@rheumatology.org.uk. Patients with lupus are at increased risk of co-morbidities, such as atherosclerotic disease, osteoporosis, avascular necrosis, malignancy and infection (2+/C). has received research funding in grants/in kind from Roche and Genentech, has acted as an advisor to Genentech, Medimmune and Rigel and has received honoraria/travel grants from Genentech, Roche and UCB. Jack Cush, MD; Feb 17, 2020 10:01 am NICE has commissioned an update to the 2010 British Society for Rheumatology (BSR) guideline for the management of giant cell arteritis (GCA), and proposed a total of 19 recommendations for the diagnosis and treatment of GCA. General recommendations for the management of lupus have not been published since 2008, although European and USA guidelines for LN management were published in 2012 [3–5]. All rights reserved. (4/D) or i.v. Disease activity is categorized into mild, moderate and severe, with the occurrence of flares (2+/C). Reimbursement for rituximab is limited to the NHS England 2013 Interim Clinical Commissioning Policy statement for rituximab in adult SLE patients (https://www.england.nhs.uk/wp-content/uploads/2013/09/a13-psa.pdf). Management of modifiable risk factors, including hypertension, dyslipidaemia, diabetes, high BMI and smoking, should be reviewed at baseline and at least annually (4/D) (SOA 98%). P.N. �� Hya�t. has received funding to attend scientific meetings and received honoraria from UCB and GlaxoSmithKline. has undertaken consultancies and received honoraria from GlaxoSmithKline/Human Genome Sciences and Roche, has been a member of the speakers’ bureau for GlaxoSmithKline/Human Genome Sciences, Union Chimique Belge (UCB) and Eli Lilly and has received research grant support from Aspreva/Vifor Pharma. Diagnosing lupus can be challenging as lupus causes a large variety of clinical features affecting any system in the body with a wide differential diagnosis and expert advice is required to confirm the diagnosis (see … Y.N. The diagnosis of lupus requires a combination of relevant clinical features and at least one immunological abnormality (as discussed below) according to the BSR guideline for lupus. NICE has accredited the process used by the BSR to produce its guidance on the management of systemic lupus erythematosus in adults. Antinuclear antibody titer is the primary laboratory test used to diagnose systemic lupus erythematosus. has consulted for Merck Serono, Eli Lilly, Celegene, UCB, XTLBio, Anthera and Baxalta; the honoraria received have been passed on to a local arthritis charity. Report of a Task Force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics, Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis, American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis, The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults, A new system for grading recommendations in evidence based guidelines, © The Author 2017. New recommendations for treating systemic lupus erythematosus were just issued by EULAR – the European League Against Rheumatism (EULAR) and published in Annals of the Rheumatic Diseases.A group of researchers from 29 medical centers across Europe reviewed all the current literature on lupus treatment to formulate questions, elicit expert opinions and reach a … doi: 10.1093/rheumatology/kex286. Histologic effects of MicroPulseâ„¢ transscleral cyclophotocoagulation in normal equine eyes. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. To assess the baseline care provided to patients with SLE attending UK Rheumatology units, audited against standards derived from the recently published MTX (1+/A), AZA (2+/C), MMF (2 ++/B), ciclosporin (2+/C) and other calcineurin inhibitors (3/D) should be considered in cases of arthritis, cutaneous disease, serositis, vasculitis or cytopaenias if HCQ is insufficient (SOA 97%). Topical preparations may be used for cutaneous manifestations, and IA injections for arthritis (4/D) (SOA 93%). has received honoraria from Actelion INB to attend scientific meetings, has undertaken consultancies and received honoraria from AstraZeneca, GlaxoSmithKline, MedImmune, Merck Serono, Pfizer, Roche and UCB and has been a member of the speakers’ bureau for GlaxoSmithKline, UCB and Pfizer. … 1 Corrigendum pertains to typing errors in section 5.1.1: “SIS<4” should read “SRI<4” and “SLI as primary endpoints” should read “S RI as primary endpoints”. K.S. Signs and symptoms of lupus may vary over time and overlap with those of many other disorders. D.J. The guidelines address the management of adult patients only and have been developed by a multidisciplinary guideline development group set up by the BSR. Neonatal lupus — Neonatal lupus is a passively acquired autoimmune disease that occurs in about 2 percent of babies born to mothers with anti-Ro/SSA and/or anti-La/SSB antibodies. It is caused by passage across the placenta after about the 20 th week of pregnancy of anti-Ro/SSA and/or anti-La/SSB antibodies to intracellular ribonucleoproteins. << /Length 5 0 R /Filter /FlateDecode >> More detailed comments about the recommendations, the supporting evidence and cautions are provided in the full guideline, available at Rheumatology Online. For the purpose of identifying patients in clinical studies, a person shall be said to have systemic lupus erythematosus if any 4 or more of the 11 criteria are present, serially or simultaneously, during any interval of observation (64,65). More recently, the British Society for Rheumatology (BSR) also published guidelines for the diagnosis, monitoring and management of SLE in adults.9 Notably, in the BSR guidelines, lupus is divided into mild, moderate and severe disease with treatment recommendations adjusted accordingly. 6 CLINICAL PRACTICE GUIDELINES IN THE SNS 6. As the disease causes significant morbidity and mortality, and can be associated with the rapid accumulation of damage if not promptly diagnosed, regularly monitored and appropriately treated, an up-to-date guideline, consistent with current National Health Service (NHS) practice, is warranted to help improve the outcome of this disease. Prednisolone treatment at a low dose of ⩽7.5 mg/day may be required for maintenance therapy (2+/C). BSR Guidelines for Giant Cell Arteritis Save. Hydroxychloroquine is recommended in all patients with lupus, at a … 4 0 obj We also provide a summary of and our strength of agreement (SOA) with the EULAR and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for LN [4] in the full guideline [6]. SLE (or lupus) is a complex, multi-system autoimmune disease that affects nearly 1 in 1000 people in the UK [1]. IVIG (2-/D) and plasmapheresis (3/D) may be considered in patients with refractory cytopaenias, thrombotic thrombocytopaenic purpura (1+/B), rapidly deteriorating acute confusional state and the catastrophic variant of APS (SOA 93%). BSPAR Guidelines. L.L. has received research grants, honoraria and consulting fees from Roche/Genentech, consulting fees from Boehringer Ingelheim, Chemocentryx, GlaxoSmithKline and Medimmune and is a Board member of Aurinia Pharmaceuticals. All other authors have declared no conflicts of interest. This guideline does not cover the evidence for topical or systemic therapy for isolated cutaneous lupus, or paediatric lupus. Management of specific clinical manifestations 175 6.1. Therapeutic objectives 178 6.1.3. Refractoriness 179 6.1.4. Keywords Lupus, cutaneous (CLE) and systemic lupus erythematosus (SLE), ‘discoid’ lupus erythematosus (DLE), efficacy endpoints, disease activity indices, claims . Because of the low prevalence of the disease in primary care populations, the antinuclear antibody titer has a low predictive v… I.N.B. Diagnosing Dyspneic Older Adult Emergency Department Patients: A Pilot Study. Scleroderma Renal Crisis as an Early Presentation of Systemic Sclerosis. 59. BSR SLE Full guideline final with all tables revised 29/12/16. ANA are present in ∼95% of SLE patients. Biologic therapies belimumab (1+/B) or rituximab (2+/C) may be considered, on a case-by-case basis, where patients have failed to respond to other immunosuppressive drugs, due to inefficacy or intolerance (SOA 98%). The guideline was developed according to the BSR Protocol for Guidelines. Clinical manifestations in SLE patients may be due to disease activity, damage, drug toxicity or the presence of co-morbidity. Typical manifestations attributed to lupus, Fatigue, malar rash, diffuse alopecia, mouth ulcers, arthralgia, myalgia, platelets 50–149 × 10, Fever, lupus-related rash up to 2/9 body surface area, cutaneous vasculitis, alopecia with scalp inflammation, arthritis, pleurisy, pericarditis, hepatitis, platelets 25–49 × 10, Rash involving >2/9 body surface area, myositis, severe pleurisy and/or pericarditis with effusion, ascites, enteritis, myelopathy, psychosis, acute confusion, optic neuritis, platelets <25 × 10, Initial typical drugs and target doses if no contra-indications, Aiming for typical maintenance drugs/doses providing no contra-indications, Aim to reduce and stop drugs except HCQ eventually when in stable remission, Copyright © 2020 British Society for Rheumatology. Caroline Gordon, Maame-Boatemaa Amissah-Arthur, Mary Gayed, Sue Brown, Ian N Bruce, David D’Cruz, Benjamin Empson, Bridget Griffiths, David Jayne, Munther Khamashta, Liz Lightstone, Peter Norton, Yvonne Norton, Karen Schreiber, David Isenberg, for the British Society for Rheumatology Standards, Audit and Guidelines Working Group, The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults: Executive Summary, Rheumatology, Volume 57, Issue 1, January 2018, Pages 14–18, https://doi.org/10.1093/rheumatology/kex291. Treatment in SLE aims at remission or low disease activity and prevention of flares. has received funding to support scientific meetings from Roche, Abbvie and Bristol-Myers Squibb. B.G. Oxford University Press is a department of the University of Oxford. The Scottish Intercollegiate Guidelines Network (SIGN) methodology [7] was used to determine the levels of evidence (LOEs) and grades of recommendations (GORs) for each statement, and these are shown in brackets below (LOE/GOR). I was hoping to print them out to take to my appointment tomorrow but cant find them anymore. April 10, 2019. Despite improvement in survival over the last 40 years, lupus patients still die on average 25 years earlier than the mean for women and men in the UK [2]. Systemic lupus erythematosus is a multisystem inflammatory disease that is often difficult to diagnose. ��Q�Y��,};�,;K�����rծ�&�/����a/�pb7�C���ͦ �������u�-nߖ>|�54�`��{.���#�z �k�o�KE��ӾD�B��r4��GD�@X��{@X���,@" �� The aim of this guideline was to produce recommendations for the management of adult lupus patients in the UK that cover the diagnosis, assessment and monitoring of lupus and the treatment of mild, moderate and severe active lupus disease, but which do not imply a legal obligation. methyl-prednisolone 500 mg × 1–3, and/or NSAIDs (for days to few weeks only), and AZA 1.5–2.0 mg/kg/day or MTX (10–25 mg/week) or MMF (2–3 g/day) or ciclosporin ≤2.0 mg/kg/day, and AZA 2–3 mg/kg/day or MMF 2–3 g/day or CYC i.v. The audit used standards derived from BSR National Institute for Health and Care Excellence (NICE) Guidelines for the Management of Adults with SLE. Published by Oxford University Press on behalf of the British Society for Rheumatology. These drugs allow for the avoidance of or dose reduction of CSs (SOA 94%). %��������� Difficult-to-treat rheumatoid arthritis: contributing factors and burden of disease, A rare case of small-vessel necrotizing vasculitis of the bone marrow revealing granulomatosis with polyangiitis, Defining colchicine resistance/intolerance in patients with familial Mediterranean fever: a modified-Delphi consensus approach, Real-world single centre use of JAK inhibitors across the rheumatoid arthritis pathway, The management of Sjögren’s syndrome: British Society for Rheumatology guideline scope, About the British Society for Rheumatology, https://doi.org/10.1093/rheumatology/kex291, https://www.england.nhs.uk/wp-content/uploads/2013/09/a13-psa.pdf, Receive exclusive offers and updates from Oxford Academic. The British Society for Rheumatology (BSR) has published The BSR guideline for the management of adults with primary Sjögren’s Syndrome.. 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