Article Update 11/12/2025

The American College of Rheumatology (ACR) released new guidelines for the treatment and management of systemic lupus erythematosus (SLE), the most common form of lupus. These guidelines replace the previous 1999 recommendations, when disease management was limited to a small number of available therapies, and there have since been important advances in the understanding and optimal use of standard and emerging rheumatology therapies.

The new guidelines include three strong recommendations: 

• Prompt tapering of glucocorticoids, with a goal to reduce prednisone dose to <5 mg daily (and ideally discontinue) within six months,
• Universal treatment with hydroxychloroquine (absent contraindications) to prevent flares and reduce accrual of damage, and
• Early initiation of escalation of immunosuppressive or biologic therapy if initial treatment is insufficient to achieve disease control.

The new guidelines aim to ensure consistent, evidence-based management of lupus, promoting early, appropriate therapy and reducing barriers to optimal care. There are 36 recommendations and good practice statements within the guidelines published by the ACR. The new guidelines include detailed guidance for general and organ-specific diseases, including musculoskeletal, cutaneous, hematologic and neurologic manifestations.

A central theme throughout the updated guidelines is shared-decision making. The ACR emphasizes that treatment should be tailored to each person's clinical presentation, values, and preferences, with patients and clinicians working together to make informed choices. This collaborative approach is highlighted as essential to improving treatment adherence, outcomes, and overall quality of care.

The final guidelines also address application of recommendations to children and adolescents with SLE, emphasizing the need to minimize glucocorticoid exposure due to its impact on growth, bone health, and puberty. They note the importance of monitoring mood, school performance, and psychosocial well-being, and recommend structured transition planning from pediatric to adult care to reduce gaps in treatment. While mental health treatment recommendations are outside the guideline’s scope, the ACR advises regular mood screening and referral to appropriate specialists when indicated. 

Organ-specific recommendations address hematologic, cutaneous, musculoskeletal, and neuropsychiatric lupus. For example, asymptomatic low white blood cell counts do not require immunosuppressive therapy, while symptomatic cytopenias may be treated with glucocorticoids plus intravenous immunoglobulin or anti-CD20 agents. For severe neuropsychiatric disease such as optic neuritis or myelitis, combination glucocorticoid and immunosuppressive therapy is conditionally recommended over glucocorticoid monotherapy. Skin and joint disease may benefit from topical or antimalarial therapies, with escalation to conventional immunosuppressants or biologics if needed. The guidelines also emphasize regular disease monitoring and prevention of complications, including infection screening, vaccination, bone health, cancer screening, and reproductive planning. These preventive measures are considered integral to comprehensive lupus care.

The Lupus Foundation of America is proud to support the development of these guidelines by connecting people living with lupus to participate in the patient panel and provide valuable experiences for the guideline’s development. Continue to follow the LFA for SLE updates and developments.

Below, you will find a video with Dr. Lisa Sammaritano, principal investigator for the ACR SLE Guideline, following a session at the 2025 Annual ACR Convergence meeting sharing about the new guidelines.