EULAR recommendations for the management of systemic lupus erythematosus: 2023 update

Antonis Fanouriakis, Myrto Kostopoulou, Jeanette Andersen, Martin Aringer, Laurent Arnaud, Sang-Cheol Bae, John Boletis, Ian N. Bruce, Ricard Cervera, Andrea Doria, Thomas Dörner, Richard A. Furie, Dafna D. Gladman, Frederic A. Houssiau, Luís Sousa Inês, David Jayne, Marios Kouloumas, László Kovács, Chi Chiu Mok, Eric F. MorandGabriella Moroni, Marta Mosca, Johanna Mucke, Chetan B. Mukhtyar, György Nagy, Sandra Navarra, Ioannis Parodis, José M. Pego-Reigosa, Michelle Petri, Bernardo A. Pons-Estel, Matthias Schneider, Josef S. Smolen, Elisabet Svenungsson, Yoshiya Tanaka, Maria G. Tektonidou, Yk Onno Teng, Angela Tincani, Edward M. Vital, Ronald F. van Vollenhoven, Chris Wincup, George Bertsias, Dimitrios T. Boumpas

Research output: Contribution to journalArticlepeer-review

3 Citations (Scopus)
4 Downloads (Pure)


Objectives: To update the EULAR recommendations for the management of systemic lupus erythematosus (SLE) based on emerging new evidence.

Methods: An international Task Force formed the questions for the systematic literature reviews (January 2018-December 2022), followed by formulation and finalisation of the statements after a series of meetings. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned, and participants finally provided their level of agreement with each item.

Results: The Task Force agreed on 5 overarching principles and 13 recommendations, concerning the use of hydroxychloroquine (HCQ), glucocorticoids (GC), immunosuppressive drugs (ISDs) (including methotrexate, mycophenolate, azathioprine, cyclophosphamide (CYC)), calcineurin inhibitors (CNIs, cyclosporine, tacrolimus, voclosporin) and biologics (belimumab, anifrolumab, rituximab). Advice is also provided on treatment strategies and targets of therapy, assessment of response, combination and sequential therapies, and tapering of therapy. HCQ is recommended for all patients with lupus at a target dose 5 mg/kg real body weight/day, considering the individual's risk for flares and retinal toxicity. GC are used as 'bridging therapy' during periods of disease activity; for maintenance treatment, they should be minimised to equal or less than 5 mg/day (prednisone equivalent) and, when possible, withdrawn. Prompt initiation of ISDs (methotrexate, azathioprine, mycophenolate) and/or biological agents (anifrolumab, belimumab) should be considered to control the disease and facilitate GC tapering/discontinuation. CYC and rituximab should be considered in organ-threatening and refractory disease, respectively. For active lupus nephritis, GC, mycophenolate or low-dose intravenous CYC are recommended as anchor drugs, and add-on therapy with belimumab or CNIs (voclosporin or tacrolimus) should be considered. Updated specific recommendations are also provided for cutaneous, neuropsychiatric and haematological disease, SLE-associated antiphospholipid syndrome, kidney protection, as well as preventative measures for infections, osteoporosis, cardiovascular disease.

Conclusion: The updated recommendations provide consensus guidance on the management of SLE, combining evidence and expert opinion.
Original languageEnglish
JournalAnnals of the Rheumatic Diseases
Early online date12 Oct 2023
Publication statusE-pub ahead of print - 12 Oct 2023


  • Autoimmune Diseases
  • Lupus Erythematosus, Systemic
  • Lupus Nephritis

Cite this