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2019 update of the EULAR recommendations for the management of systemic lupus erythematosus
  1. Antonis Fanouriakis1,
  2. Myrto Kostopoulou2,
  3. Alessia Alunno3,
  4. Martin Aringer4,
  5. Ingeborg Bajema5,
  6. John N Boletis6,
  7. Ricard Cervera7,
  8. Andrea Doria8,
  9. Caroline Gordon9,
  10. Marcello Govoni10,
  11. Frédéric Houssiau11,
  12. David Jayne12,
  13. Marios Kouloumas13,
  14. Annegret Kuhn14,
  15. Janni L Larsen15,
  16. Kirsten Lerstrøm16,
  17. Gabriella Moroni17,
  18. Marta Mosca18,
  19. Matthias Schneider19,
  20. Josef S Smolen20,
  21. Elisabet Svenungsson21,
  22. Vladimir Tesar22,
  23. Angela Tincani23,
  24. Anne Troldborg24,
  25. Ronald van Vollenhoven25,
  26. Jörg Wenzel26,
  27. George Bertsias27,
  28. Dimitrios T Boumpas1,28,29
  1. 1 Rheumatology and Clinical Immunology Unit, “Attikon” University Hospital, Athens, Greece
  2. 2 Department of Nephrology, “G. Gennimatas” General Hospital, Athens, Greece
  3. 3 Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
  4. 4 Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
  5. 5 Department of Pathology, Leiden University Medical Center, Leiden, Netherlands
  6. 6 Nephrology Department and Renal Transplantation Unit, “Laikon” Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
  7. 7 Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
  8. 8 Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
  9. 9 Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
  10. 10 Department of Medical Sciences, Section of Rheumatology, University of Ferrara, Azienda Ospedaliero-Universitaria Sant'Anna Ferrara, Ferrara, Italy
  11. 11 Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
  12. 12 Department of Medicine, Addenbrooke's Hospital, Cambridge, UK
  13. 13 Cyprus League Against Rheumatism, Aglantzia, Cyprus
  14. 14 University Hospital Muenster, Muenster, Germany
  15. 15 Copenhagen Lupus and Vasculitis Clinic, Rheumatology and Spine Diseases Centre, Rigshospitalet, Copenhagen, Copenhagen, Denmark
  16. 16 Lupus Europe, Farum, Denmark
  17. 17 Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
  18. 18 Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
  19. 19 Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
  20. 20 Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
  21. 21 Department of Medicine, Rheumatology Unit, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
  22. 22 Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
  23. 23 Rheumatology and Clinical Immunology, University of Brescia, Brescia, Italy
  24. 24 Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
  25. 25 Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers, Amsterdam, Netherlands
  26. 26 Department of Dermatology and Allergy, University Hospital Bonn, Bonn, Germany
  27. 27 Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
  28. 28 Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
  29. 29 Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, Athens, Greece and Medical School, University of Cyprus, Nicosia, Cyprus
  1. Correspondence to Dr Antonis Fanouriakis, Rheumatology and Clinical Immunology Unit, “Attikon” University Hospital, Athens 12462, Greece; afanour{at}


Our objective was to update the EULAR recommendations for the management of systemic lupus erythematosus (SLE), based on emerging new evidence. We performed a systematic literature review (01/2007–12/2017), followed by modified Delphi method, to form questions, elicit expert opinions and reach consensus. Treatment in SLE aims at remission or low disease activity and prevention of flares. Hydroxychloroquine is recommended in all patients with lupus, at a dose not exceeding 5 mg/kg real body weight. During chronic maintenance treatment, glucocorticoids (GC) should be minimised to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn. Appropriate initiation of immunomodulatory agents (methotrexate, azathioprine, mycophenolate) can expedite the tapering/discontinuation of GC. In persistently active or flaring extrarenal disease, add-on belimumab should be considered; rituximab (RTX) may be considered in organ-threatening, refractory disease. Updated specific recommendations are also provided for cutaneous, neuropsychiatric, haematological and renal disease. Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion.

  • systemic lupus erythematosus
  • treatment
  • lupus nephritis

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  • GB and DTB contributed equally.

  • Handling editor David S Pisetsky

  • Contributors AF and MK performed the systematic literature review (SLR) and AF drafted the manuscript. GB supervised the methodology of the SLR and edited the manuscript. DTB convened and supervised the project and edited the manuscript. All authors edited the manuscript and accepted its final form.

  • Funding AF was supported by an Articulum Fellowship and a grant from the Hellenic Society of Rheumatology during the completion of this work.

  • Competing interests AF reports personal fees from GSK, Abbvie, Amgen, Enorasis and Genesis Pharma, outside the submitted work. MA reports fees from advisory boards from Novartis, Pfizer, Roche. IB reports personal fees from consultant for GSK, outside the submitted work. JNB reports grants from GSK, personal fees from GSK, personal fees from Abbvie, personal fees from UCB, personal fees from Enorasis, grants from Pfizer, outside the submitted work. RC reports personal fees from GSK, personal fees from Astra Zeneca, personal fees from Rubió, outside the submitted work. DJ reports personal fees from Astra-Zeneca, Aurinia, Boehringer-Ingeleheim, Celgene, BMS, Chemocentryx, grants and personal fees from GSK, from null, outside the submitted work. AK reports grants from Biogen, grants from Galderma, grants from GlaxoSmithKline, grants from Leo Pharma, personal fees from La Roche Posay, outside the submitted work. MM reports personal fees from GSK, Lilly and UCB. MS reports grants from GSK, UCB, Abbvie, outside the submitted work. JSS reports grants from AbbVie, Astra-Zeneca, Janssen, Lilly, MSD, Novartis, Pfizer and Roche, and personal fees from AbbVie, Amgen, Astra-Zeneca, Astro, BMS, Celgene, Celltrion, Chugai, Gilead, ILTOO, Janssen, Lilly, MSD, Novartis-Sandoz, Pfizer, Roche, Samsung, Sanofi and UCB, during the conduct of the study. AT reports personal fees from UCB, Pfizer, Abbvie, BMS, Sanofi, Roche, GSK, Alpha Sigma, Lilly, Jannsen, Cellgene and Novartis, outside the submitted work. RvV reports grants from BMS, GSK, Lilly, Pfizer, UCB Pharma, personal fees from AbbVie, AstraZeneca, Biotest, Celgene, GSK, Janssen, Lilly, Novartis, Pfizer, Servier, UCB, outside the submitted work. JW reports grants from GSK, grants from Incyte, personal fees from Biogen, personal fees from Leo, other from Novartis, during the conduct of the study. GB reports grants from GSK, Pfizer and personal fees from GSK, Abbvie, UCB and Enorasis, outside the submitted work. DTB reports unrestricted grant support/advisory board fees from Abbvie, BMS, Celgene, Enorasis, GSK, Pfizer, Novartis, UCB, Lilly, all deposited to the research account of the National and Kapodistrian University of Athens.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.