2025 ACR Lupus Treatment Guidelines for All Ages

In May 2025, the American College of Rheumatology (ACR) updated its lupus treatment guidelines. The updates in the guidelines are meant to reflect scientific advances, and the new guidelines prioritize early biologic use, steroid-sparing approaches, and shared decision-making between clinicians and patients.

*Disclaimer:

The information provided in this article is for general informational purposes only and is not intended as medical advice. It should not be used as a substitute for professional diagnosis, treatment, or advice from a qualified healthcare provider. Reliance on any information provided in this article is solely at your own risk.

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One of the updates is the use of biologics (medications from living organisms) into standard treatment. Biologics are recommended in earlier stages, especially for patients with moderate-to-severe lupus who remain active after initial treatments (like hydroxychloroquine and low-dose immunosuppressants).

• Belimumab: Targets B-cell activating factor (BAFF). Recommended for both adults and children over age 5.

• Anifrolumab: Blocks type I interferon signaling. Used for patients with cutaneous and musculoskeletal difficulties.

Corticosteroids (like prednisone) can be effective but are known to become toxic over time. The ACR now recommends minimizing steroids as early as possible.

• The goal is to get to ≤7.5 mg/day of prednisone within 6 months.

• Immunosuppressants and biologics should be used to reduce the need for steroids.

Children often have more severe symptoms. The guidelines recommend getting a specialist involved early, starting stronger treatment quickly, and closely watching growth, puberty, and how well they stick to their medications.

In older patients, lupus is usually milder but can be more complicated due to other health issues, and in turn, the possibility of taking multiple medications. The ACR recommends using lower doses and carefully weighing the risks and benefits, especially when using immunosuppressants or biologics.

The guidelines offer targeted approaches based on organ involvement:

Lupus nephritis: Treatment often starts with mycophenolate mofetil or low-dose cyclophosphamide. Belimumab or azathioprine can be used later to help keep the disease under control. An early kidney biopsy and working closely with a kidney specialist are important.

Cutaneous lupus: Hydroxychloroquine is still the first-choice treatment. Anifrolumab is suggested for cases that don’t respond well to other treatments. Lifestyle changes (avoiding sun exposure, quitting smoking, etc) are also important.

Neuropsychiatric lupus: A team-based evaluation is important to prevent misdiagnosis. Immunosuppressive treatment is only used for inflammatory brain or nervous system symptoms. Strong focus on supporting mental health.

One of the most important parts of the 2025 update is shared decision-making, where patients are encouraged to take an active role in choosing their treatments by considering the risks, benefits, and their personal lifestyle. This approach is especially important for:

• Teens moving from pediatric to adult care.

• Patients making decisions about pregnancy and family planning.

• Communities with less access to care, especially Black, Indigenous, and Latino patients (who are more often affected by lupus).

The ACR also highlights the need to consider social factors, like insurance, transportation, and language barriers, when planning treatment.

The 2025 ACR guidelines push for earlier use of effective treatments like biologics and less long-term steroid use. Additionally, doctors are encouraged to focus on prevention and personalized care with patients being involved in decisions. All of this leads to faster symptom control, fewer side effects, and better collaboration, which may improve outcomes and bring new hope to people with lupus.

Lupus Guideline | American College of Rheumatology

EULAR recommendations for the management of systemic lupus erythematosus: 2023 update | BMJ Journals

Steroids in Lupus: Enemies or Allies | National Library of Medicine

Disparities in Lupus and the Role of Social Determinants of Health: Current State of Knowledge and Directions for Future Research | National Library of Medicine