Bonnie L. Bermas

Objective: To evaluate whether extending the American College of Rheumatology–recommended monitoring interval for complete blood count and liver function tests in patients receiving methotrexate (MTX) affects timely detection of medication‐related toxicity. Methods: We conducted an observational cohort analysis of 14,199 laboratory encounters from 2,439 patients receiving MTX with at least two measurements of alanine aminotransferase (ALT), aspartate aminotransferase (AST), white blood cell (WBC) count, hematocrit (HCT), mean corpuscular volume (MCV), and/or platelet (PLT) count. Fibrosis‐4 (FIB‐4) scores were calculated when possible. Changes between consecutive measurements were plotted against time between encounters. Monitoring intervals of three months (45–135 days) and six months (135–225 days) were compared. After propensity score matching, we assessed incident clinically relevant abnormalities. Results: Testing frequency showed no meaningful correlation with changes in ALT, AST, WBC, HCT, MCV, PLT, or FIB‐4 (all R ² < 0.01). Mean laboratory changes did not differ meaningfully between monitoring intervals. Patients monitored every 135 to 225 days were equally or less likely to develop incident abnormal results than those monitored every 45 to 135 days; most odds ratios (ORs) were not statistically significant ( P > 0.05). Patients in the six‐month group were less likely to develop ALT >1× upper limit of normal (OR 0.72 [95% confidence interval (CI) 0.52–0.99]) or MCV >100 fL (OR 0.67 [95% CI 0.46–0.96]). Conclusion: Extending routine MTX monitoring from every three months to every six months was not associated with more severe abnormalities or delayed detection of toxicity, suggesting quarterly testing may be more frequent than necessary and could be reconsidered to reduce cost and patient burden.

Appropriately addressing reproductive health requires that a provider know a patient's contraceptive method and interest in pregnancy; this information is often missing from rheumatology visit documentation. A Learning Collaborative (LC) comprised of experts and clinical rheumatologists implemented data collections methods for reproductive health information during clinic visits. Patient-level data was extracted from the electronic medical record for community sites (Sites A, B, and C) and aggregate data was collected for up to 30 patients per month from academic sites (Sites D and E). The LC included 5 clinics. The community sites created flagged, easy-to-access data-fields; this was not feasible at academic sites. Medical assistants documented patient information at Sites A and B; providers at Sites C, D, and E. Sites A and B had rapid and significant increases in documentation of contraception and pregnancy interest. Two providers at Site C significantly improved; others had modest increases. Contraception documentation increased at Site D but not Site E. Among 1,982 women in Sites A, B, and C, 48.6% had contraception documented, more frequently among younger patients, those with SLE, and those taking a teratogen. Pregnancy intention was documented in 50.1% of women, 9.5% of whom reported potential interest. Routinely documenting contraception and pregnancy interest is feasible in academic and community rheumatology practices. Documentation is enhanced by flagged data fields and completion by medical assistants or very engaged providers.

Objective: To assess the impact of renal replacement therapy in people with lupus nephritis (LN)–associated end‐stage kidney disease (ESKD) and support the development of the 2024 American College of Rheumatology LN treatment guidelines. Methods: We conducted a systematic literature review and meta‐analysis to address three Population, Intervention, Comparison, and Outcome (PICO) questions related to renal replacement therapy for ESKD due to LN, including comparisons of kidney transplant versus dialysis, hemodialysis versus peritoneal dialysis, and preemptive kidney transplant versus no preemptive kidney transplant. Outcomes of interest included mortality, cardiovascular (CV) events, infections, lupus flares, disease‐related damage, graft failure, and quality of life. We conducted a meta‐analysis and analyzed hazard ratios for time‐to‐event analyses and risk ratios for dichotomous outcomes, as well as absolute risk estimates. Results: Sixteen comparative observational studies addressed at least one of the three PICO questions. Kidney transplant was found to reduce the risks of all‐cause mortality, CV mortality, infection‐related mortality, and CV events compared with dialysis (high certainty). Dialysis modality (peritoneal vs hemodialysis) was not associated with mortality (high certainty) or with other outcomes of infection, CV complications, and systemic lupus erythematosus flares (low certainty). Preemptive kidney transplant was associated with lower risks of graft failure and mortality (low certainty). Conclusion: This systematic review identified improved outcomes with kidney transplant versus dialysis for people with LN‐associated ESKD and potential benefits of preemptive kidney transplant. This evidence supports the use of kidney transplant as a preferred renal replacement therapy for people with LN‐ESKD.

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.

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.

Objective: A patient‐centered approach for chronic disease management, including systemic lupus erythematosus (SLE), aligns treatment with patients’ values and preferences, leading to improved outcomes. This paper summarizes how patient experiences, perspectives, and priorities informed the American College of Rheumatology (ACR) 2024 Lupus Nephritis (LN) and 2025 SLE screening, treatment guidelines. Methods: We completed a cross‐sectional qualitative study using content analysis of two Patient Panel meetings for the ACR LN and SLE guidelines. Key themes were presented by Patient Panel representatives during Voting Panel Meetings along with evidence for each recommendation, to ensure comprehensive discussions and align treatment recommendations with patients’ priorities and values. Results: Nineteen people (90% women) with diagnoses of SLE and/or LN participated in the Patient Panels and 17 consented to use their feedback for analysis. Thematic analysis of their discussions revealed nine patient‐reported key themes in three domains: (1) treatment and monitoring of LN and SLE: medication side effects, daily function, treatment goals, and monitoring and screening; (2) clinical communication: strategies to optimize communication and provider and structural impediments to effective communication; and (3) improving transparency and information sharing: clinical trial participation, and medical costs and insurance coverage. These themes were actively incorporated into discussions during the Voting Panels for the ACR LN and SLE guidelines. Conclusion: This work supported the integration of patient experiences in the clinical practice guideline development process and aligned recommendations with real‐world patient experiences and priorities, thereby enhancing the clinical applicability of the ACR LN and SLE guidelines. image