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2025 American College of Rheumatology (ACR) Guideline for the Treatment of Systemic Lupus Erythematosus

Lisa R Sammaritano 1, Anca Askanase 2, Bonnie L Bermas 3, Maria Dall’Era 4, Alí Duarte-García 5, Linda T Hiraki 6, Mary Beth F Son 7, Victoria P Werth 8, Cynthia Aranow 9, April Barnado 10, Anna Broder 11, Hermine I Brunner 12, Benjamin F Chong 3, Vaidehi R Chowdhary 13, Aimee O Hersh 14, Peter M Izmirly 15, Marimee Jules 16, Kenneth Kalunian 17, Diane Kamen 18, Tamar B Rubinstein 19, Benjamin J Smith 20, Natalie M Smith 21, Asha Thomas 22, Homa Timlin 23, Daniel J Wallace 24, Muayad Azzam 25, Christie M Bartels 26, Joanne S Cunha 27, Kimberly DeQuattro 28, Andrea Fava 23, Gabriel Figueroa-Parra 29, Shivani Garg 26, Lais Lopes Almeida Gomes 8, Maria C Cuéllar-Gutiérrez 30, Priyanka Iyer 31, Andrew S Johannemann 32, April Jorge 33, Shanthini Kasturi 34, Hassan Kawtharany 25, Jana Khawandi 25, Alexandra Legge 35, Kimberly P Liang 25, Megan M Lockwood 36, Alain Sanchez-Rodriguez 37, Marat Turgunbaev 38, Jessica N Williams 39, Amy S Turner 38, Reem A Mustafa 25

Abstract

Objective: To provide evidence-based and expert guidance for the treatment and management of non-renal systemic lupus erythematosus (SLE); treatment and management of lupus nephritis are addressed in a separate guideline.

Methods: Clinical questions for treatment and management of SLE were developed in the PICO format (population, intervention, comparator, and outcome). Systematic literature reviews were developed for each PICO question, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess evidence quality and formulate recommendations. The Voting Panel achieved a consensus of ≥70% agreement on the direction (for or against) and strength (strong or conditional) of each recommendation.

Results: We present recommendations and ungraded, consensus-based good practice statements for the treatment and management of SLE that are applicable to pediatric and adult patients. Recommendations emphasize uniform treatment with hydroxychloroquine, limiting duration of glucocorticoid use, and early introduction of conventional and/or biologic immunosuppressive therapies to achieve and maintain control of SLE inflammation (remission or a low level of disease activity), reduce SLE-related morbidity and mortality, and minimize medication-related toxicities.

Conclusion: This guideline presents direction regarding treatment and management of SLE and provides a foundation for well-informed, shared clinician-patient decision-making. These recommendations should not be used to limit or deny access to therapies, as treatment decisions may vary due to the unique clinical situation and personal preferences of each person with SLE.

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