Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) for SLE
The role of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) for SLE is well established. The drug chosen will depend on the clinical presentation; for example, severe arthritis in SLE would preferentially be treated with methotrexate, in addition to oral hydroxychloroquine. The usual dosage of methotrexate for SLE in adults isFanouriakis, 2019:
1methotrexate 10 to 25 mg orally, on one specified day once weekly methotrexate methotrexate methotrexate
OR
1methotrexate 10 to 25 mg subcutaneously, on one specified day once weekly methotrexate methotrexate methotrexate
PLUS with either of the above
folic acid 5 to 10 mg orally, weekly (not on the same day as methotrexate). folic acid folic acid folic acid
For additional considerations specific to methotrexate use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).
Azathioprine may be used, in addition to oral hydroxychloroquine, to treat haematological features of SLE, such as haemolytic anaemia. The usual dosage of azathioprine for SLE in adults isFanouriakis, 2019:
azathioprine 1.5 to 2.5 mg/kg orally, daily. azathioprine azathioprine azathioprine
For additional considerations specific to azathioprine use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).
Mycophenolate may be used, in addition to oral hydroxychloroquine, to treat significant lupus nephritis. The usual dosage of mycophenolate for SLE in adults isFanouriakis, 2019:
1mycophenolate mofetil 500 to 3000 mg orally, daily in 2 divided doses1 mycophenolate mofetil mycophenolate mofetil mycophenolate mofetil
OR
1mycophenolate sodium 180 to 720 mg orally, twice daily. mycophenolate sodium mycophenolate sodium (mycophenolic acid) mycophenolate sodium (mycophenolic acid)
For additional considerations specific to mycophenolate use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).
Cyclophosphamide remains in use for adults with SLE, but other immunomodulatory drugs are preferred over cyclophosphamide because of its adverse effects on both male and female fertility and potential teratogenicity. Cyclophosphamide is sometimes given as pulse intravenous therapy for severe features of SLE, such as pulmonary haemorrhage, crescentic lupus nephritis or cerebral (neuropsychiatric) diseaseFanouriakis, 2019. Drug regimens differ in various institutions; refer to local protocols if cyclophosphamide is being considered. For additional considerations specific to cyclophosphamide use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs)
Tacrolimus may be used, in addition to oral hydroxychloroquine, to treat significant lupus nephritisFanouriakis, 2019. The usual dosage of tacrolimus for SLE in adults is:
tacrolimus 2 to 4 mg orally, daily in 2 divided doses. tacrolimus tacrolimus tacrolimus
For additional considerations specific to tacrolimus use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).Check serum creatinine concentration every 3 to 4 months in all people taking tacrolimus to assess for potentially subtle drug toxicity.
Ciclosporin may occasionally be used, in addition to oral hydroxychloroquine, for lupus nephritis and resistant cutaneous featuresFanouriakis, 2019. The usual dosage of ciclosporin for SLE in adults is:
ciclosporin 1.5 to 3 mg/kg orally, daily in 2 divided doses. ciclosporin ciclosporin ciclosporin
For additional considerations specific to ciclosporin use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).