The GLADEL–PANLAR guideline update separates mild skin and joint lupus from moderate-to-severe disease and gives clinicians a regimen-specific approach to active proliferative lupus nephritis. The societies call this the 2025 update to their 2018 recommendations. The final version appeared in Nature Reviews Rheumatology on 12 November 2026.
Treat to target while reducing steroid exposure
Aim for remission or low disease activity, with sustained remission as the longer-term goal. The good-practice statements support antimalarial therapy unless contraindicated and minimising glucocorticoid exposure. Dose and monitoring should reflect the individual balance of disease control and toxicity. Assess activity over time and incorporate the patient's symptoms, priorities and access to care.
Skin and joints: severity guides escalation
For mild musculoskeletal or cutaneous disease in adults, the panel conditionally favours antimalarial-based treatment, with glucocorticoids or a conventional immunosuppressant when indicated, over adding biologic or targeted treatment early. This is a new recommendation with moderate-to-high evidence certainty.
For moderate-to-severe joint or skin manifestations, the panel conditionally recommends adding belimumab or anifrolumab to antimalarial-based treatment. Glucocorticoids and conventional immunosuppressants may form part of that background regimen. Evidence certainty is moderate to high. For refractory musculoskeletal lupus, adding rituximab is a conditional recommendation supported by low-certainty evidence. Persistent symptoms warrant reassessment for active inflammation and other contributors before escalation.
Proliferative nephritis: match the add-on to the regimen
The conditional initial treatment recommendation covers adults with active class III or IV lupus nephritis, with or without concurrent class V. The recommended combinations include antimalarial therapy and glucocorticoids with the conventional immunosuppressive regimen.
| Conventional regimen | Add-on options specified by the panel |
|---|---|
| Mycophenolic acid analogue | Voclosporin, tacrolimus, obinutuzumab or belimumab |
| Intravenous cyclophosphamide | Belimumab |
Evidence certainty varies by agent: high for belimumab and voclosporin, moderate for obinutuzumab and low for tacrolimus. After renal response, the panel conditionally suggests antimalarial therapy and a mycophenolic acid analogue, with or without glucocorticoids, plus either belimumab or obinutuzumab. This subsequent-therapy recommendation has low-certainty evidence.
Applying the guideline
Use the dominant organ manifestation and severity to select the pathway. Discuss benefits, risks, reproductive plans, monitoring and access before selecting a regimen. The guideline was developed for Latin American practice, where availability and cost can determine whether a regimen is feasible. Table 1 summarises recommendation strength and evidence certainty, and Figures 2 and 3 show the skin, joint and kidney pathways.
Original guideline
Pons-Estel GJ, Isnardi CA, Nieto RE, et al. GLADEL–PANLAR clinical practice guidelines for the management of systemic lupus erythematosus: 2025 update. Nature Reviews Rheumatology. Published 12 November 2026. Read the original guideline .