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The paper on the First Latin American clinical practice guidelines for the treatment of systemic lupus erythematosus (SLE) points to some conclusions that need to be further clarified since the bulk of evidence points to a different direction.1 Belimumab safety and efficacy has been well documented since its approval during the last 5 years, and in particular the skin and joint domains appear to have a preferential site of major clinical improvement associated with reduction of flares and steroid tapering.2 However, the authors when placing the best available evidence of therapy for those domains group belimumab with methotrexate and leflunomide for joint manifestations and indicates superiority favouring methotrexate. For the mucocutaneous manifestations, belimumab is grouped with methotrexate, azathioprine, mycophenolate, cyclosporine and cyclophosphamide, and due to cost and availability, recommendation favours methotrexate and azathioprine.
We feel that this degree of recommendation fails to overview the best medical literature published in the past few years pointing to the superiority of belimumab in improving joint and skin disease when compared with other domains, allowing maintenance of steroid sparing and decrease of adverse events by continuous use of daily steroids also reducing the use of immunosuppressive drugs.3 4 The authors should explain how that conclusion could be reached even when cost issues are raised since there is well-published literature pointing to benefits of belimumab in the long run for several social services when compared with cheaper immunosuppressive drugs that do not reduce steroid intake and lead to increased adverse events and opportunistic infections.5 The upcoming opportunity to use the subcutaneous route of administration will certainly create additional opportunities for patients with SLE with active disease that could benefit from add-on existing therapies6 The recent questioning of expert consensus on expert consensus addresses this approach properly and indicates that, although nice, it is not necessarily relevant to accuracy.7
Handling editor Josef S Smolen
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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