Reply to Zandstra and van der Voort

and van der Voort that the recommendation should be a grade A that SUP should not be used, our methodology for grading in this situation could be debated. One could take the position that the placebo-controlled clinical trials used to support the value of SUP are not large enough to engender an A grade and that a grade C would be more appropriate. Also making two separate recommendations, one for use of SUP and one for choice of agent, may be more practical as it would allow different grading for each. These options will be considered in the next revision of the guidelines.