New Lupus Guidelines Emphasize Hydroxychloroquine as the Cornerstone of Care
After 25 years, the American College of Rheumatology issues major updates highlighting treatment balance, shared decision-making, and steroid minimization.
The American College of Rheumatology (ACR) has released its first systemic lupus erythematosus (SLE) management guideline since 1999, reaffirming hydroxychloroquine (HCQ) as the backbone of therapy for most patients. The update calls for steroid tapering, individualized use of biologics, and greater patient engagement in treatment decisions.
Study Details:
The 2025 guideline, published in Arthritis & Rheumatology and Arthritis Care & Research, reflects two decades of clinical advances in lupus treatment. The ACR panel comprising nearly 50 experts integrated new data on biologics, immunosuppressants, and long-term disease management outcomes.
The update aligns U.S. recommendations more closely with the European Alliance of Associations for Rheumatology (EULAR) 2023 guideline, which also recognizes HCQ as the therapeutic foundation for lupus.
Methodology:
The guideline was developed using systematic reviews of the literature and expert consensus. Recommendations were graded based on evidence strength and patient input. Many were labeled conditional due to variability in clinical presentation and limited comparative trials. The process included a patient panel to emphasize the importance of tolerability and adherence in real-world care.
Key Findings:
Hydroxychloroquine remains central: Should be continued indefinitely if tolerated.
Corticosteroids limited: Use only for short-term control of flares or new diagnoses; taper rapidly.
Immunosuppressants/biologics: Add or escalate if low disease activity (LDA) or remission is not achieved on HCQ and minimal steroids.
Remission/LDA as goals: Target steroid dose ≤5 mg/day prednisone equivalent.
Tapering window: Consider reducing immunosuppressants after 3–5 years of stable remission.
Expanded drug list: Includes 20 medications with dosing and monitoring guidance, such as belimumab, anifrolumab, rituximab, and tacrolimus.
Implications for Practice:
For clinicians, the guideline reinforces a structured yet flexible approach HCQ as baseline therapy, cautious steroid use, and selective use of biologics based on organ involvement. The emphasis on shared decision-making aims to boost adherence, a known challenge in lupus management.
For patients, this represents progress toward safer, more personalized care acknowledging quality of life, side effects, and the need for sustained remission without chronic steroid exposure.