EULAR 2023 recommendations for the management of systemic lupus erythematosus: A global perspective

The European Alliance of Associations for Rheumatology (EULAR) has released its updated recommendations for the management of systemic lupus erythematosus (SLE), reflecting significant global contributions from experts across four continents. Since their inception in 2008, these guidelines have become essential for clinicians treating this complex autoimmune disease. The 2023 update emphasizes a streamlined set of 13 recommendations, incorporating new therapeutic strategies and aiming for improved patient outcomes. 

Glucocorticoids (GC) remain a critical component in the management of SLE, offering rapid symptom relief. However, their long-term use is associated with risks, including infections, metabolic disturbances, cardiovascular events, and irreversible organ damage. The latest recommendations continue the trend of reducing the maintenance dose of GCs, with the new acceptable threshold set at ≤ 5 mg/day of prednisone equivalent, a decrease from the previous ≤7.5 mg/day. This change is based on the observational data suggesting that lower doses are associated with reduced damage accrual in patients with low disease activity. For moderate to severe disease, the use of GC pulses (250–1000 mg/day for 1–3 days) is recommended to facilitate faster tapering. Notably, low-dose pulse regimens are as effective as higher doses, supporting their use to minimize side effects. The ultimate goal remains complete GC withdrawal, although this is challenging in clinical practice due to the potential for disease flare. 

A significant update in the 2023 recommendations is the strong advocacy for the early use of immunosuppressive (IS) drugs and biological agents. The approval of anifrolumab, a monoclonal antibody targeting the type I interferon receptor, has expanded therapeutic options for SLE. The recommendations support the addition of immunosuppressive agents and biologics like belimumab or anifrolumab in patients who do not respond to hydroxychloroquine or cannot reduce GC <5 mg/day. Importantly, there is no mandated hierarchy between IS and biologic therapies. This approach reflects the significant efficacy and safety demonstrated by biologics in large clinical trials, although their high cost remains a consideration. Despite this, the task force emphasizes that conventional immunosuppressives should be tried first in most cases due to variable access to biologics globally. 

For lupus nephritis (LN), the 2023 recommendations highlight the potential for upfront combination therapies. Cyclophosphamide (CYC) and mycophenolate mofetil (MMF) remain cornerstone treatments, but recent trials have shown the benefits of adding belimumab or voclosporin. These combination therapies should be considered, though they are not mandated, recognizing the variable response rates and potential overtreatment concerns. The recommendations underscore the importance of individualized treatment plans, considering factors like drug accessibility, safety profiles, and patient preferences. The continuation of IS treatment for at least three years following clinical response is suggested to maintain disease control. 

 The 2023 EULAR recommendations for SLE management represent a significant step forward, incorporating global expert insights and the latest therapeutic advancements. While these guidelines provide a comprehensive framework for treating SLE, it is important to tailor the treatment approach based on the patient’s needs. 


Moysidou GS, Fanouriakis A. EULAR 2023 Recommendations for the Management of Systemic Lupus Erythematosus: One Step Forward. Mediterr J Rheumatol. 2024 Mar 31;35(1):63-65.