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International and multidisciplinary expert recommendations for the use of biologics in systemic lupus erythematosus

Jean-François Kleinmann 1 Florence Tubach 2 Veronique Le Guern 3 Alexis Mathian 4 Christophe Richez 5 David Saadoun 6 Karim Sacré 7 Jérémie Sellam 8 Raphaèle Seror 9 Zahir Amoura 10 Emmanuel Andrès 11, 12 Sylvain Audia 13 Brigitte Bader-Meunier 14 Gilles Blaison 15 Bernard Bonnotte 13 Patrice Cacoub 6 Sophie Caillard 16 Laurent Chiche 17 Olivier Chosidow 18 Nathalie Costedoat-Chalumeau 19 Claire Daien 20 Eric Daugas 7 Nairouz Derdèche 12 Andrea Doria 21 Olivier Fain 22 Fadi Fakhouri 23 Dominique Farge 24 Cem Gabay 25 Sylvie Guillo 26 Eric Hachulla 27 Najia Hajjaj-Hassouni 28 Mohamed Hamidou 29 Frédéric Houssiau 30 Noemie Jourde-Chiche 31, 32 Isabelle Kone-Paut 33 Aïcha Ladjouz-Rezig 34 Olivier Lambotte 9 Dan Lipsker 35 Xavier Mariette 9 Nicolas Martin-Silva 36 Thierry Martin 37 François Maurier 38 Roderich Meckenstock 39 Arsene Mekinian 40 Olivier Meyer 41 Shirine Mohamed 42, 43 Jacques Morel 44 Bruno Moulin 45 Denis Mulleman 46 Thomas Papo 47 Vincent Poindron 48 Xavier Puéchal 49 Leonardo Punzi 21 Pierre Quartier 50 Laurent Sailler 51 Amar Smail 52 Martin Soubrier 53 Agnès Sparsa 54 Zoubida Tazi-Mezalek 55 Leith Zakraoui 56 Stéphane Zuily 43 Jean Sibilia 57 Jacques-Eric Gottenberg 58
Abstract : Background/purpose: Despite conventional immunosuppressants, active and steroid-dependent systemic lupus erythematosus (SLE) represents a therapeutic challenge. Only one biologic, belimumab, has been approved, but other biologics are sometimes used off-label. Given the lack of evidence-based data in some clinical situations encountered in real life, we developed expert recommendations for the use of biologics for SLE. Methods: The recommendations were developed by a formal consensus method. This method aims to formalize the degree of agreement among experts by identifying, through iterative ratings with feedback, the points on which experts agree, disagree or are undecided. Hence, the recommendations are based on the agreed-upon points. We gathered the opinion of 59 French-speaking SLE experts from 3 clinical networks dedicated to systemic autoimmune diseases (FLEUR, IMIDIATE, FAI2R) from Algeria, Belgium, France, Italy, Morocco, Switzerland and Tunisia. Represented medical specialities were internal medicine (49%), rheumatology (34%), nephrology (7%), dermatology (5%), pediatrics (3%) and cardiology (2%). Two methodologists and 3 strictly independent SLE expert groups contributed to developing these recommendations: a steering group (SG) (n=9), an evaluation group (EG) (n=28) and a reading group (RG) (n=22). Preliminary recommendations were drafted by the SG, then proposed to the EG. Each EG member rated the degree of agreement from 1 to 9 (1: lowest; 9: strongest) for each recommendation. After 2 rating rounds, the SG submitted a new version of the recommendations to the RG. With comments from the RG, the SG finalised the recommendations. Results: A total of 17 final recommendations were formulated by the SG, considering all agreement scores and comments by the EG and RG members and the two methodologists. These recommendations define the subset of patients who require a biologic; the type of biologics to use (belimumab, rituximab, etc.) depending on the organ involvement and associated co-treatments; what information should be given to patients; and how to evaluate treatment efficacy and when to consider discontinuation. Conclusion: Overall, 17 recommendations for the good use of biologics in SLE were formulated by a large panel of SLE experts to provide guidance for clinicians in daily practice. These recommendations will be regularly updated according to the results of new randomized trials and increasing real life experience.
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Jean-François Kleinmann, Florence Tubach, Veronique Le Guern, Alexis Mathian, Christophe Richez, et al.. International and multidisciplinary expert recommendations for the use of biologics in systemic lupus erythematosus. Autoimmunity Reviews, Elsevier, 2017, 16 (6), pp.650-657. ⟨10.1016/j.autrev.2017.04.011⟩. ⟨hal-01787368⟩

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