Table 1.

List of recommendations with level of evidence and grade of recommendation, agreement, cost/risk ratio

Recommendation	Level of evidence and grade of recommendation	Agreement	Cost/risk
1. Patient assessment.     In addition to the standard care of patients without lupus of the same age and sex, the assessment of     patients with SLE must include the evaluation of:       disease activity by a valid  ated index at each visit       organ damage annually       general quality of life by patient history and/or by a 0–10 VAS (patient global score) at each visit       comorbidities       drug toxicity	5, D	97.6	L/VL
2. Cardiovascular risk factors     At baseline and during follow-up at least once a year:       assess smoking, vascular events (cerebral/cardiovascular), physical activity, oral contraceptives,       hormonal therapies and family history of cardiovasculardisease       perform blood tests: blood cholesterol, glucose       examine for blood pressure, body mass index (and/or waist circumference)     NB: some patients may need more frequent follow-up (ie, patients on glucocorticoids)	1b, B	98.1	L/VL
3. Othercomorbidities     Osteoporosis. All patients with SLE:       should be assessed for adequate calcium and vitamin D intake, re  gular exercise and smoking       habits       should be screened and followed for osteoporosis according to existing guidelines (a) for       postmenopausal women; (b) for patients on steroids, or on any other medication that may       reduce BMD     Cancer. Cancer screening is recommended according to the guidelines for the general population,     including cervical smear tests	2b, C	93.8	M/VL
	2b, C	92.3	M/L
4. Infection risk     Screening. We recommend that patients should be screened for:       HIV based on the patient’s risk factors       HCV, HBV based on the patient’s risk factors, particularly before IS drugs including high dose       glucocorticoids are given       tuberculosis, according to local guidelines, especially before IS drugs including high dose       glucocorticoids are given       CMV testing should be considered during treatment in selected patients.     Vaccination. Patients with SLE are at high risk of infections, and prevention should be     recommended.     The administration of inactivated vaccines (especially flu and pneumococcus), following the     Centers for Disease Control (CDC) guidelines for patients who are immunosuppressed, should be     strongly encouraged in patients with SLE on IS drugs, preferably administered when the SLE is     inactive. For other vaccinations, an individual risk/benefit analysis is recommended.     Monitoring. At follow-up visits, continuous assessment of the risk of infection by taking into     consideration the presence of       severe neutropenia (<500 cells/mm3)       severe lymphopenia (<500 cells/mm3)       low IgG (<500 mg/dl)	2b, C	98.8	M/VL
	5, D	93.5	M/M
	1b, B	88.8	M/VL
5. Frequency of assessments     In patients with no activity, no damage, no comorbidity we recommend assessments every     6–12 months. During these visits, preventive measures should be emphasised.	5, D	93.8	M/L
6. Laboratory assessment     We recommend the monitoring of the following autoantibodies and complement:       at baseline: ANA, anti-dsDNA, anti-Ro, anti-La, anti-RNP, anti-Sm, anti-phospholipid, C3, C4       re-evaluation in previously negative patients of: ant  i-phospholipid antibodies: prior to       pregnancy, surgery, transplant and use of oestrogen-containing treatments, or in the presence of a       new neurological or vascular event; anti-Ro and anti-La antibodies before pregnancy; anti-       dsDNA/C3C4 may support evidence of disease acti  vity/remission     Other laboratory assessments. At 6–12 months intervals patients with inactive disease should     have:       complete blood count       erythrocyte sedimentation rate       C reactive protein       serum albumin       serum creatinine (or eGFR)       urinalysis and urine protein/creatinineratio     NB: if a patient is on a specific drug treatment, monitoring for that drug is required as well	2b, C	92.3	M/VL
	5, D	89.5	M/VL
7. Mucocutaneous involvement     Mucocutaneous lesions should be characterised, according to the existing classification systems,     as to whether they may be:       LE specific       LE non-specific       LE mimickers       drug-related     Lesions should be assessed for activity and damage, using validated indices (ie, CLASI)	5, D	94.6	M/L
8. Kidney       Patients with a persistently abnormal urinalysis or raised serum creatinine should have urine       protein/creatinine ratio (or 24 h proteinuria), urine microscopy and renal ultrasound, and be       considered for referral for biopsy.       Patients with established nephropathy should have protein/creatinine ratio (or 24 h proteinuria)       and immunological tests (C3, C4, anti-dsDNA), urine microscopy and blood pressure at least       every 3 months for the first 2–3 years.       Patients with established chronic renal disease (eGFR <60 ml or stable proteinuria >0.5 mg/24       h) should be followed according to the National Kidney Foundation guidelines for chronic kidney       disease.	1b, B	94.2	H/M
9. Neuropsychiatric manifestations     Patients with SLE should be monitored for the presence of neuropsychological symptoms     (seizures, paresthesiae, numbness, weakness, headache, epilepsy, depression, etc) by focused     history.     Cognitive impairment may be assessed by evaluating attention, concentration, word finding and     memory difficulties (ie, by asking the patient about problems with multitasking, with household     tasks, or memory). If there is a suspicion of any cognitive impairment, then the patient should be     assessed in further detail.	2b, D	87.7	M/VL
10. Eye assessment     In patients treated with glucocorticoids or antimalarials, a baseline eye examination is     recommended according to standard guidelines. An eye examination during follow-up is     recommended:       in selected patients taking glucocorticoids (high risk of glaucoma or cataracts)       in patients on antimalarial drugs, and (a) low risk: no further testing is required until after 5 years       of baseline, after the first 5 years of treatment eye assessment is recommended yearly; (b) high       risk: eye assessment is recommended yearly.	2b, D	95.8	M/L

ANA, anti-nuclear antibodies; BMD, bone mineral density; CLASI, Cutaneous Lupus Disease Area and Severity index; CMV, cytomegalovirus; dsDNA, double-stranded DNA; eGFR, estimated glomerular filtration rate; H, high; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; IS, immunosuppressive; L, low; LE, lupus erythematosus; M, moderate; SLE, systemic lupus erythematosus; VAS, visual analogue scale; VH, very high; VL, very low.