<p>The new American College of Rheumatology (ACR) systemic lupus erythematosus (SLE) guidelines presented at the recent <strong>ACR Convergence 2025</strong> meeting replace the 1999-era recommendations with modern, organ-based, steroid-sparing strategy recommendations. The updated guidelines define remission, recommend a target prednisone dose of 5 mg/day or lower, endorse universal hydroxychloroquine, and encourage the early use of immunosuppressants and biologics, with shared decision making and treatment adherence sitting at the center.</p> <p><br></p> <p><em>Following these presentations, featured expert Anca D. Askanase, MD, MPH, was interviewed by</em> Conference Reporter <em>Associate Editor-in-Chief Christopher Ontiveros, PhD. Clinical perspectives from Dr Askanase are presented here.</em></p>

At ACR Convergence 2025, my colleagues and I presented on the updated ACR treatment guidelines for SLE and how to apply them to different clinical scenarios. The previous version of the nonrenal guidelines was released in 1999, so they are definitely “antiques,” and updated guidelines have been long awaited.

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Innovative features of the updated guidelines include defining the target of remission as definition of remission in SLE (DORIS) remission and defining a new glucocorticoid target for stable controlled SLE of 5 mg/day or less, with 0 mg/day being ideal. I think that these are novel ways of thinking about SLE management that hopefully will change practice. I also think that the concept of the early introduction of immunosuppressants and biologics for patients with SLE is another key recommendation. The nonrenal guidelines highlight the concept of minimizing steroid use, which means that we need to introduce steroid-sparing agents early in the disease course. They also propose a stepwise approach to treating flares, first with hydroxychloroquine and steroids, followed by a traditional DMARD with a low threshold to introduce 1 of the 2 US Food and Drug Administration (FDA)–approved biologics for SLE, anifrolumab and belimumab.

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Hydroxychloroquine is recommended for everyone and has been the backbone of SLE treatment for decades. The part of the updated ACR guidelines that I think is different is that we are looking for a daily hydroxychloroquine dose goal of 5 mg/kg or less to reduce the risk of retinal toxicity. Shivani Garg, MD, PhD, and colleagues presented an abstract at the ACR Convergence 2025 meeting on using hydroxychloroquine blood levels to better guide treatment efficacy and evaluate safety (abstract 1722). However, the guidelines do not recommend measuring hydroxychloroquine blood levels because there is a concern that this is not available for a lot of practicing rheumatologists. As there is an increased availability to measure hydroxychloroquine blood levels, hopefully clinicians will start using this more rational approach to hydroxychloroquine dosing compared with per kg dosing.

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As opposed to the earlier ACR guidelines and other rheumatology society guidelines on SLE, the updated ACR guidelines make recommendations using a per organ system treatment approach, which we hope is going to be very useful to practicing rheumatologists. Ultimately, in practice, when you are with a patient with SLE, you are evaluating the overall disease but are focused on organizing treatment around the most acute manifestations. For example, if your patient’s most acute manifestation is lupus nephritis, then you treat with the target of complete renal response in mind. If arthritis is the main clinical manifestation, then your treatment is focused on resolving the arthritis. If it is cutaneous disease, central nervous system disease, or serositis, you think about the patient’s main active clinical manifestation and the organs that are at the greatest risk of being damaged. I think that, because we made the deliberate choice of recommending per organ system treatments, hopefully rheumatologists will find the updated ACR guidelines to be very practical in their daily practice and will be more effective at treating SLE.

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Shared decision making is another guiding principle that is emphasized in the updated treatment guidelines. Things are not so black and white in SLE, so shared decision making is critical. Assessing treatment adherence is also important, but shared decision making could be the path to improving adherence. Ultimately, prescribing a medication that the patient with SLE can access and that aligns with their values and life goals is going to help with treatment adherence.

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Overall, I think that there was a lot of enthusiasm for the guidelines at ACR Convergence 2025. The large primary room (where we were presenting the updates), as well as the back-up room, were filled with attendees. The audience was ready to listen to the guideline updates, and we made a big splash.