• Lupus Erythematosus, Systemic
• Therapeutics
• Lupus Nephritis

We thank Drs Roberts et al for their interest in the updated EULAR recommendations for the management of systemic lupus erythematosus (SLE), and for the important points they raise.1 Prompted by a phrase in the manuscript text, that race, as an ‘immutable’ characteristic, should be taken into account during the choice of therapy for an individual patient with SLE, they argue that racial differences in treatment responses or other disease parameters are driven by socioeconomic factors and by potential discrimination against certain racial or ethnic groups, as a result of racism.

We share the authors’ sincere concern regarding ongoing inequities in access to care against non-privileged societal groups, and the need to stress—as much as possible—the importance of equal access for all patients, regardless of race, ethnicity or other characteristics. Indeed, accumulating evidence suggests that social determinants of health have an important impact on the disparities that characterise systemic lupus erythematosus (SLE) and its outcomes around the world.2

This being said, however, we believe that it may be overly simplistic to view all differences in SLE as a result of marginalisation of specific racial or ethnic minorities. There is ample genetic evidence to support that the increased risk of Black or Asian individuals to develop SLE, lupus nephritis or adverse outcomes of the latter (end-stage kidney disease, death) cannot be solely explained by socioeconomic factors.3 4 Even after taking these factors into account, race and ethnicity still hold an important role, possibly owing to increased genetic burden and autoantibody reactivity in non-white individuals.5

To conclude, the 2023 EULAR recommendations for SLE by no means ‘endorse a race-based approach to care’. Rather, they state that all patients with SLE should receive optimal multidisciplinary care in centres with expertise in the disease, in order to ensure a favourable long-term outcome. Recognising that this is often not the reality, particularly for patients with lower socioeconomic status, we thank Roberts et al for highlighting the need to tackle the ongoing societal parameters that perpetuate disparate access to care.