Response to: ‘Clinical evidence guidelines in systemic lupus erythematosus: revaluation’ by Scheinberg

We want to thank Dr Morton Scheinberg for his interest1 in our recent lupus guidelines communication.2 In his letter, he points out several concerns regarding belimumab which we had recommended at the same therapeutic level as other immunosuppressants for joint and skin manifestations. Few clarifications are needed. The development of our guidelines followed a rigorous methodology in which the evidence on effect estimates should come, when available, from randomised controlled trials (RCTs). We did not identify any clinical trial comparing belimumab against other immunosuppressants. Therefore, in considering this comparison, the development group had to rely on indirect evidence (the difference in belimumab effect against placebo and other immunosuppressants against placebo) or high risk of bias evidence (from observational studies). In this context, the panel agreed that the certainty that belimumab was better (or worse) than other immunosuppressants was low/very low and therefore decided not to recommend one over the others...