International guidelines for lupus are variable, and could lead to confusion over the best management finds an Australian systematic review.

The review of nine clinical practice guidelines and five consensus statements, including guidelines from the American College of Rheumatology (ACR) and the European League against Rheumatism (EULAR), found that in areas where there was a strong evidence base, guidelines tended to concur.

But in other areas where there was little or no evidence, guidelines could be quite variable, says lead author David Tunnicliffe, a doctoral candidate at the Sydney School of Public Health.

“Comparatively high quality evidence is available for class III and IV lupus nephritis induction therapy, for example, but if you look at lupus nephritis classes II and V, there’s less overlap and some guidelines don’t mention these classes because there’s no evidence,” he says.

There was “substantial variability” in the treatments recommended for class II and V lupus nephritis and recommendations for the duration of maintenance therapy of classes III and IV varied between one and four years, the authors said.

For patients taking anti-malarial medication one guideline recommended an ophthalmological examination annually while another said every five years.

In the realm of diagnosis there was considerable agreement, however: “The ACR criteria for classification of patients with SLE, is widely used as a diagnostic aid,” the authors said. In patients with four of the 11 criteria, a diagnosis of SLE can be made with 95% specificity and 85% sensitivity, they added.

The guidelines were assessed using a tool called AGREE II. The scores for ‘applicability’ were consistently low with only EULAR’s 2010 Monitoring SLE guideline scoring above 50%.

“Applicability scores will be higher if there are algorithms or other tools that are easy to use,” says Tunnicliffe. Only the Treat to Target 2014 guideline specifically involved patients in the guideline development.

While eleven of the 14 guideline and consensus documents reported undertaking a systematic literature review as part of their development, only four reported that their recommendations had been subjected to peer review.

There is a need for collaborative and multidisciplinary efforts to develop comprehensive, high-quality evidence-based guidelines for SLE, the authors concluded.

“I work in nephrology guideline development and generally, in that field, there is a move towards international collaboration. I believe this may also be the case in rheumatology” says Tunnicliffe.

In total eight of the sets of guidelines were published by rheumatology societies or working groups.