Rheumatology Guideline Updates Take New Life Course Approach

Medscape

21-05-2025

MANCHESTER, England — The latest guidelines on systemic sclerosis (SSc), axial spondyloarthritis (axSpA), and systemic lupus erythematosus (SLE) from the British Society for Rheumatology (BSR) have been updated and, where appropriate, now consider the full life course of these rheumatologic diseases, experts said at BSR 2025 Annual Meeting.
BSR Clinical Guidelines Program Manager Lindsay Turner told Medscape Medical News that the approach was 'really valuable because often it's hard to get evidence in a pediatric population. The updates now mean that recommendations relevant to that population are included.'
BSR guidelines are generally updated every 5 years, unless evidence becomes available that warrants a 'mini update,' Turner said.
But that time schedule can get stretched out over longer periods, as occurred with the SSc guideline update, as Christopher Denton, MBChB, PhD, professor of experimental rheumatology at UCL Medical School in London, England, told Medscape Medical News .
'Obviously, COVID got in the way for 2 years,' he said. 'And of course, the process itself takes at least 2 years. So I think inevitably that even if you start to do the update, it's going to be about 7-8 years.'
SSc Guideline Highlights
Denton, who is also head of the Centre for Rheumatology at the Royal Free Hospital, London, England, presented highlights only of the updated SSc guideline at the conference because these have already been published.
Christopher Denton, MBChB, PhD
One of the key recommendations he highlighted is to use nailfold capillaroscopy during the diagnosis of SSc, as this is as important as antinuclear antibody testing, taking the history, and a physical examination.
Moreover, all patients diagnosed with SSc should have a baseline assessment done regardless of what treatment plan is being considered and that should include bloodwork, ECGs, echocardiograms, pulmonary function tests, and a high-resolution CT (HRCT).
Discussing the HRCT recommendation, Denton said: 'I think it does reflect the importance of knowing as early as possible whether there is interstitial lung disease present and also to help you follow patients noninvasively over time.'
Another 'cornerstone' of the updated guidance is being vigilant and looking out for potential complications, such as malignancy.
As for treatment, 'the general recommendation, or preference, was that mycophenolate mofetil is the drug that seems to be the most effective for diffuse cutaneous disease and for interstitial lung disease and limited skin involvement,' Denton said.
The guideline also tries to make it clear when autologous hematopoietic stem cell transplantation (AHSCT) may or may not be suitable based on current evidence and states that this approach must be delivered within an experienced specialized center.
As such, the recommendation is that AHSCT may be considered an option for diffuse cutaneous SSc, where the benefit is felt to outweigh any risks. However, if there is severe internal organ disease, then this approach may not be appropriate and careful evaluation is required.
Also, while AHSCT may be considered an option for children and young people who have severe or refractory disease, regardless of whether they have diffuse cutaneous or limited disease, it is not for adults who have later-stage diffuse cutaneous or limited disease because there is not enough evidence currently to support its use, Denton said.
AxSpA Guideline Highlights
As for the updated axSpA guideline on management using biologic and targeted synthetic disease-modifying antirheumatic drugs, Sizheng Steven Zhao, MBChB, PhD, clinical senior lecturer and honorary consultant in rheumatology at The University of Manchester, Manchester, England, said there were three key points.
Sizheng Steven Zhao, MBChB, PhD
First, be open to re-evaluating the diagnosis, Zhao said: 'Getting the diagnosis right can be challenging. Be humble. Be open with your patients about the uncertainty around diagnosis and be willing to revisit that. Re-look at the [MRI] images if treatment response doesn't make sense.'
Second, 'start recording the ASDAS [Ankylosing Spondylitis Disease Activity Score],' Zhao said, in addition to recording disease activity using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI).
Recording the BASDAI is a requirement of the National Institute for Health and Care Excellence, but using ASDAS is 'where the future is. That's where we're moving toward,' Zhao said. He indicated that this should not be too difficult to incorporate into routine practice given that rheumatologists are already using scores such as the DAS in 28 joints for rheumatoid arthritis.
Third, do not rule out using certain drug classes. 'Although we're blessed with three classes of drug, we only still have three classes of drug for a condition that needs many decades of treatment. Don't reflexively rule out a mechanism of action,' Zhao said.
Specifically, he mentioned not ruling out the use of interleukin 17 inhibitors in a patient who had uveitis or inflammatory bowel disease (IBD). Work with ophthalmologists and gastroenterologists on a case-by-case basis to see if that drug class could still be suitable, Zhao said.
Three overarching principles have been added to the guidance, which consider the goals for treatment, shared care decision-making, and the need for a multidisciplinary approach. Zhao urged his audience to read these and the full guideline, which was published in April. There were 'a lot of nuances,' put into the writing of overarching principles and the 15 recommendations, he said.
The recommendations have been grouped into three broad areas: General, which covers starting, monitoring, and switching treatments; extra-musculoskeletal manifestations (EMMs), which includes uveitis, psoriasis, and IBD; and treatment strategy, which encompasses the treat-to-target approach, tapering, and treatment withdrawal.
The BSR guideline is unique in its discussion of EMMs, Zhao said. This is not done in the American or European guidelines to the same extent: 'We spent that much time thinking about this because, quite frankly, all the therapies have similar efficacy across musculoskeletal features. It is the EMMs that influence which one we choose.'
Zhao emphasized that physical therapy was not to be ignored and that pharmacologic treatments were there to 'enable our patients to continue physical activity, not instead of physical therapy.'
SLE Guideline Highlights
The updated BSR guideline for the management and treatment of SLE is just a few weeks away from publication, said Md Yuzaiful Md Yusof, MBChB, PhD, consultant rheumatologist and senior research fellow at the University of Leeds and Leeds Teaching Hospitals NHS Trust, both in Leeds, England.
Md Yuzaiful Md Yusof, MBChB, PhD
The updated guideline covers a much broader scope than its previous iteration, as it now includes recommendations for the management of children and adolescents, as well as adults. Literature searches were done from inception rather than from where the last guideline left off, 'particularly for the pediatric field,' Md Yusof said.
Detailed guidance on the management of lupus nephritis has been included, and other new features of the guideline were the inclusion of cutaneous lupus, nonpharmacologic care, and the delivery of care, Md Yusof said.
Of course, he added, 'we can't do it all,' and areas not covered were neonatal lupus, contraception and reproductive health, treatment during pregnancy and breastfeeding, complications and comorbidities, and detailed management of thrombosis and antiphospholipid syndrome. However, other national guidelines should already cover these topics.
The guideline included 102 recommendations. 'I know it sounds a bit alarming, but they're quite logical and self-explanatory,' Md Yusof said. Overall, 96 of these are shown in a single infographic which is intended to act as a 'cheat code,' he added.
The recommendations concern diagnosis, assessment and monitoring, management, and the delivery of care. In terms of diagnosis, timing is key, Md Yusof said. When primary care physicians have a strong suspicion of SLE, they should be looking to refer to secondary or tertiary care within 3 weeks, he said.
Treat-to-target is one of the key recommendations regarding assessment and monitoring. The primary treatment goal is to meet the 2021 Definition of Remission in SLE criteria, Md Yusof said. And if that is not possible, the target should be to reach the Lupus Low Disease Activity State.
As for management, there is guidance on what rheumatologists could prescribe for cutaneous disease without consulting a dermatologist, such as non-facial topical glucocorticoids and non-facial topical calcineurin inhibitors.
The of use of the British Isles Lupus Assessment Group (BILAG)-2004 index and SLE Disease Activity Index 2000 to guide management choices was recommended, with the addition of Easy-BILAG, Md Yusof said.
'We recommend all people with mild lupus to be on hydroxychloroquine at a dose of 5 mg/kg of actual body weight per day,' he said. Glucocorticoids could be used as bridging therapy to settle disease flare but not for routine long-term maintenance.
For moderate to severe disease activity, methotrexate or immunosuppression with mycophenolate mofetil, azathioprine, cyclosporin, or tacrolimus is recommended to be started early if there is no organ- or life-threatening disease. Biologics and trials are then advocated for more moderate to severe disease, where there is no renal involvement or if glucocorticoids could not be withdrawn. Trials, belimumab, rituximab, or anifrolumab are recommended for more severe disease activity.
Regarding lupus nephritis, all patients should be managed jointly between rheumatology and renal services.
'Timely biopsy is really key, and also identifying poor prognostic markers from the outset,' Md Yusof said.
A key message regarding glucocorticoid use is to put an end date on the prescription and 'to make sure you have a tapering plan.' Detailed advice is provided in the guideline on how to taper appropriately.
The recommendation on induction treatment for lupus nephritis is the most up-to-date available, with combination therapy recommended over single-agent mycophenolate mofetil. 'Whichever combination that you use for remission induction, you carry on for the maintenance,' Md Yusof added.
He concluded that the British guidelines were 'definitely more directive and also more up-to-date' than other available guidelines.
Turner reported having no relevant financial relationships. Denton reported receiving research and grant funding and consultancy and speaker fees from or acting as a clinical trial investigator and serving on a steering committee for more than 20 companies. Zhao reported receiving consultancy or speaker fees from AbbVie, Alfasigma, Novartis, and UCB. He also acknowledged receiving financial support for attending conferences from Alfasigma, Eli Lilly & Company, Novartis, and UCB. Md Yusof reported acting as an advisory board member, consultant, or speaker for Alumis, Aurinia, GlaxoSmithKline, Novartis, Roche, UCB, and Vifor.