Compare the three major guidelines for lupus erythematosus and see the Asia-Pacific management consensus

Only for medical professionals to read and reference.
In July 2021, the Asia-Pacific Association of Rheumatism Societies Consensus on the management of systemic lupus erythematosus was released
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What is the difference between this Asia-Pacific guide and the latest European Union guide and the Chinese guide? Let me break down.
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Systemic lupus erythematosus (SLE) is common in Asia, but due to medical care, patient drug tolerance and treatment in the Asia-Pacific region Compliance varies, leading to uneven prognosis
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At the same time, due to differences in clinical phenotypes, medical care approaches, and cultural backgrounds, the clinical management of SLE in Europe and the United States is not fully applicable to the treatment decisions of Asian patients
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In this context, in order to provide guidance to rheumatologists, family doctors, specialist nurses and other health care professionals in the Asia-Pacific region, the Asia-Pacific Association of Rheumatology Societies has formulated the first consensus statement on SLE management in the Asia-Pacific region[1] , And published in the journal "The Lancet-Rheumatology" on July 1, 2021
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Picture: The Consensus on Management of Systemic Lupus Erythematosus of the Alliance of Asia-Pacific Rheumatism Societies was published in the "Lancet-Rheumatology" magazine and the latest "2020 China Systemic Lupus Erythematosus Diagnosis and Treatment Guidelines" [2] (hereinafter referred to as the Chinese Guidelines) and Comparison of the 2019 European Alliance against Rheumatism Management Guidelines for Systemic Lupus Erythematosus[3] (hereinafter referred to as the European Guidelines), the differences in the “Asia Pacific Rheumatism Association Alliance Systemic Lupus Erythematosus Management Consensus” (hereinafter referred to as the Asia Pacific Guidelines) Mainly reflected in the following aspects
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01 Guideline Makers Asia Pacific Guidelines believe that SLE should be managed by a multidisciplinary team composed of lupus specialists, nurses and other health care professionals, and doctors and patients should jointly develop a management plan
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And the voices of 3 representatives of SLE patients were included in the development of the guideline
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The Chinese guidelines and European guidelines are both formulated by SLE-related medical experts
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02 Treatment Goals Asia Pacific Guidelines: Reduce organ damage, ensure long-term survival, and improve health-related quality of life
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Chinese guidelines: The treatment goals are divided into short-term and long-term goals; the treatment principle of SLE is determined to be early and individualized treatment, which can delay disease progression to the greatest extent, reduce organ damage, and improve prognosis
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European guidelines: To achieve clinical remission or low disease activity in all organs, and prevent recurrence, use the smallest dose of hormones as possible to maintain treatment; when lupus relapses, treatment should be adjusted according to the severity of the involved organs, including increasing the dose of existing drugs and changing the dressing Or add new drugs
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03 Treatment Strategies ■ Asia Pacific Guidelines: Unless there are contraindications, it is recommended that all patients with SLE use hydroxychloroquine routinely
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The maintenance dose of hydroxychloroquine should not exceed 5 mg/(kg·d)
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In view of the adverse effects of treatment, immunotherapy should not be given or adjusted for patients who are only serologically active
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■ Chinese guidelines: Long-term use of hydroxychloroquine is recommended for SLE patients without contraindications as the basic treatment; for SLE patients whose hormone combined with hydroxychloroquine is not effective, or patients who cannot adjust the dose of hormones below a relatively safe dose, it is recommended to use Immunosuppressive agents; for those with organ damage, it is recommended to add immunosuppressive agents during initial treatment
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■ European guidelines: Unless there are contraindications, hydroxychloroquine is recommended for all patients with SLE, with a dose not exceeding 5 mg/kg of actual body weight
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If the patient uses hydroxychloroquine with poor efficacy (single agent or in combination with hormones) or the hormone cannot be reduced to 7.
5 mg/d of prednisone, immunosuppressive agents such as methotrexate and azathioprine can be added; if the disease is at risk Organ function, immunosuppressive agent can be added to the initial treatment; cyclophosphamide can be used as the initial treatment of severely endangering organ function or life-threatening SLE, or as a rescue treatment for other immunosuppressive agents ineffective
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The comparison shows that the three guidelines all emphasize the importance of hydroxychloroquine, but the Asia-Pacific guidelines emphasize that the maintenance dose of hydroxychloroquine should not exceed 5 mg/(kg·d)
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It also pointed out that immunotherapy should not be given or adjusted for patients who only have serological activities
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In addition, the Asia-Pacific guidelines suggest that cardiovascular and bone health should be regularly assessed and optimized through pharmacological or non-pharmacological means
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Specifically, it is recommended to measure the bone density within 6 months after the start of glucocorticoids, and to monitor the bone density repeatedly within 1 to 3 years according to the risk of fracture
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For patients with moderate to high fracture risk calculated according to the fracture risk assessment tool formula and adjusted glucocorticoid dose, oral or intravenous injection of bisphosphonate, denosumab or teriparatide is recommended
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04 Prevention of infection complications ■ Asia Pacific Guidelines: It is recommended to screen and treat active hepatitis B virus (HBV) infection and hepatitis C virus (HCV) infection (HBsAg, anti-HCV antibody) before receiving immunosuppressive therapy
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For patients receiving B cell depletion therapy or enhanced immunosuppression, occult hepatitis B screening (IgG antibodies against HBcAg and HBV DNA) and pre-treatment should be considered
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Active tuberculosis should be ruled out before immunosuppression
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Routine screening and treatment of latent tuberculosis are not recommended
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High-risk patients may consider preventing pneumocystis pneumonia during immunosuppression
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It is recommended that during the epidemic period (including COVID-19), the prevention and control measures specified in the national guidelines (such as maintaining physical distance, personal hygiene, wearing masks) should be followed
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Immunosuppressive drugs should not be discontinued, unless in an active infection that requires a personalized decision after discussion with an infectious disease expert
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It is recommended to vaccinate seasonal influenza, pneumococcal, human papillomavirus and herpes zoster during the quiescent period of the disease and when the dose of immunosuppressants is minimal
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■ Chinese guidelines: During the entire treatment period of SLE, possible infection risks should be assessed in a timely manner, and infections should be identified, prevented, and controlled in a variety of ways
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■ European guidelines: SLE patients need to be assessed for the risk of infection, whether there are the following high-risk factors for infection: old age/weakness, diabetes, kidney involvement, immunosuppressant or biological treatment and hormones
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It is recommended to take preventive measures to prevent infection, including vaccines, and try to identify and treat the infection as early as possible
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By comparison, it can be seen that the Asia-Pacific Guidelines make specific recommendations for the prevention and treatment of infectious diseases
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05 Lupus Nephritis ■ Asia Pacific Guidelines: Unless there are contraindications, renal biopsy should be performed before immunosuppressive therapy for active lupus nephritis (LN)
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Mycophenolate mofetil or standard-dose intravenous cyclophosphamide combined with medium-dose glucocorticoids are recommended as the induction regimen for active LN
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Low-dose cyclophosphamide intravenous injection or tacrolimus combined with medium-dose glucocorticoid can be used as a second-line induction program
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The dosage of mycophenolate mofetil should be adjusted according to body weight
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The initial dose for Asian patients is usually 2 g/d
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The mycophenolate mofetil/tacrolimus combination or rituximab may be considered for patients with active LN who do not respond well to standard regimens
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Mycophenolate mofetil or azathioprine can be used for maintenance therapy
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If mycophenolate mofetil has been used for induction therapy, mycophenolate mofetil is the first choice for maintenance therapy
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When there are contraindications or intolerances to mycophenolate mofetil and azathioprine, low-dose calcineurin inhibitors can be used for maintenance therapy
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Maintenance treatment of LN should be continued for at least 5 years to prevent recurrence of nephritis
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■ Chinese Guidelines: According to the pathological classification, the opinions recommend Type I lupus nephritis: the treatment should be selected according to the extrarenal manifestations
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Type II lupus nephritis: It is recommended to use hormones and/or immunosuppressive agents for treatment
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Type Ⅲ, type Ⅳ and non-simple type Ⅴ lupus nephritis: It is recommended to use hormones combined with cyclophosphamide or mycophenolate mofetil in the remission induction period, and to use mycophenolate mofetil or azathioprine in the maintenance phase
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Simple type V lupus nephritis with renal proteinuria: It is recommended to use medium-dose hormones in combination with mycophenolate mofetil or calmodulin inhibitor or azathioprine, and it is recommended to use angiotensin converting enzyme inhibitor (ACEI)/vascular tension ARB II receptor blocker (ARB) strictly controls blood pressure
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■ European guidelines: Early identification of renal involvement should be done.
If LN is present, perfect diagnostic renal puncture can ensure optimal treatment
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In the LN-induced remission phase, mycophenolate mofetil or low-dose intravenous cyclophosphamide is recommended
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In patients at high risk of renal failure (decreased glomerular filtration rate, pathological fibro crescent and fibrinoid necrosis, or renal tubular atrophy/interstitial fibrosis), remove mycophenolate mofetil or low-dose intravenous ring For the phosphoramide regimen, a high-dose cyclophosphamide regimen can also be considered
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LN maintains the remission stage and uses mycophenolate mofetil
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If the patient's renal function is stable or improved, but renal remission is incomplete, renal puncture should be repeated to identify acute or chronic disease
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In patients with severe nephrotic syndrome or incomplete renal remission, if there is no uncontrollable high blood pressure, high chronic score of nephropuncture pathology, and decreased glomerular filtration rate, it can be combined on the basis of mycophenolate mofetil Small doses of calmodulin inhibitors
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The three guidelines all attach great importance to LN, and the Asia-Pacific guide has made specific recommendations for Asians on the dosage and use of mycophenolate mofetil
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06 Neuropsychiatric Systemic Lupus Erythematosus■ Asia Pacific Guidelines: Medium or high-dose glucocorticoids (including methylprednisolone intravenous pulse therapy) combined with cyclophosphamide is the first-line treatment for severe neuropsychiatric SLE symptoms caused by inflammation; including but not limited to Psychosis, acute confusional state, myelitis, cranial and peripheral neuropathy, and aseptic meningitis
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Rituximab may be considered for the treatment of refractory neuropsychiatric SLE symptoms caused by inflammation
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Symptomatic treatment and reversal of aggravating factors are important for certain neuropsychiatric symptoms (such as epilepsy, depression, and cognitive dysfunction)
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For patients with neuropsychiatric SLE with thrombosis and antiphospholipid antibody positive, anticoagulation therapy is required
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■ Chinese guidelines: It is recommended to diagnose neuropsychiatric lupus through clinical manifestations, hematology and cerebrospinal fluid examinations, and neuroimaging manifestations, and to differentiate it from the neurological symptoms caused by antiphospholipid syndrome
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For severe neuropsychiatric lupus, hormonal shock therapy is recommended first, and cyclophosphamide can be added when the effect is not good
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■ European guidelines: To identify whether neuropsychiatric manifestations are related to SLE, it is necessary to combine neuroimaging, cerebrospinal fluid testing, risk factors (type of neuropsychiatric manifestations, whether it is accompanied by the onset of lupus, patient age, manifestations of lupus activity outside the nervous system, and whether there is resistance to Phospholipid antibodies), and exclude other confounding factors
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Treatment of SLE-related neuropsychiatric manifestations: use hormone/immunosuppressive therapy for inflammatory manifestations, and use antiplatelet/anticoagulation therapy for antiphospholipid antibody-related manifestations
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Compared with the Chinese and European guidelines, the Asia-Pacific guidelines introduce rituximab to treat refractory neuropsychiatric SLE symptoms caused by inflammation
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07 Antiphospholipid Syndrome ■ Asia Pacific Guidelines: For patients with antiphospholipid syndrome with high-risk antiphospholipid antibodies with thrombosis, vitamin K antagonists are better than direct oral anticoagulants
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Low-dose aspirin (75-100 mg/d) can be considered as the primary prevention of thromboembolic events in patients with a high-risk antiphospholipid antibody profile and (or) without other risk factors for atherosclerosis
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■ China Guidelines: No relevant recommendations for combating phospholipid syndrome
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■ European guidelines: All patients with SLE should be screened for antiphospholipid antibodies
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SLE patients with high-risk antiphospholipid antibodies, after weighing the risk of bleeding, can consider using antiplatelet drugs for primary prevention of thrombosis, especially when combined with other atherosclerotic/thrombogenic factors
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If thrombosis or sick pregnancy has occurred, the treatment principle is the same as that of primary antiphospholipid syndrome
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Compared with the Chinese guidelines and European guidelines, the Asia-Pacific guidelines recommend specific types and dosages of anticoagulant drugs
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08 Other In addition to the above aspects, the Asia-Pacific Guidelines also make relevant recommendations on other aspects of SLE: For severe and life-threatening SLE manifestations (for example, hematology, cardiopulmonary, gastrointestinal tract), the combined use of medium to large doses of glucocorticoids should be considered Hormones (including methylprednisolone intravenous shock therapy) and cyclophosphamide
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For thrombotic thrombocytopenic purpura, pulmonary hemorrhage and some hematological manifestations, such as hemophagocytic syndrome, plasma exchange may be considered
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For refractory SLE, especially when there are hematological manifestations or other immunosuppressive regimens contraindicated, intravenous immunoglobulin G can be considered
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Methotrexate may be considered for persistent skin or joint disease
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For patients with active SLE that is difficult to cure with standard therapies, belyumumab may be considered
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Maintenance treatment options include azathioprine, mycophenolate mofetil, and calcineurin inhibitors
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In the treatment of SLE, biosimilars and generic drugs (such as rituximab, mycophenolate mofetil, or tacrolimus) are acceptable alternatives
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On the whole, the three guidelines have their own strengths.
The European guidelines will be relatively more authoritative in the world.
The Chinese guidelines incorporate the results of local Chinese circulation, and the Asia-Pacific guidelines are very instructive for the treatment of SLE in the entire Asia-Pacific region
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References: [1] Chi Chiu Mok,Laniyati Hamijoyo,Nuntana Kasitanon,Der Yuan Chen,Sheng Chen,Kunihiro Yamaoka,et al.
The Asia-Pacific League of Associations for Rheumatology consensus statements on the management of systemic lupus erythematosus.
The Lancet Rheumatology.
2021;3(7):E517-E531.
[2] Chinese Medical Association Rheumatology Branch, National Clinical Research Center for Skin and Immune Diseases, China Systemic Lupus Erythematosus Research Cooperative Group.
2020 China Systemic Lupus Erythematosus Diagnosis Guidelines[J].
Chinese Journal of Internal Medicine,2020,59(3):172-185.
[3]Fanouriakis A,Kostopoulou M,Alunno A,Aringer M,Bajema I,Boletis JN,et al.
2019 update of the EULAR recommendations for the management of systemic lupus erythematosus.
Ann Rheum Dis.
2019;78(6):736-45.