Other immunomodulatory drugs for SLE in children and adolescents
Other immunomodulatory drugs may be used, in addition to hydroxychloroquine and systemic corticosteroids, for management of severe organ- and life-threatening features of SLE in children and adolescents. These drugs include:
For children and adolescents with SLE, these drugs have increasing roles as first-line treatments and for long-term corticosteroid sparing. For considerations regarding immunomodulatory therapy (including adverse effects, monitoring, screening for infection, vaccination, and reproductive health), see Principles of immunomodulatory drug use.
Many of the drugs used in the treatment of SLE have potentially adverse effects on reproductive health in both females and males. The choice of immunomodulatory drugs needs careful consideration in people of childbearing potential, including children and adolescents. See Reproductive health in people with systemic lupus erythematosus.
If azathioprine is indicated for a child or adolescent with SLE, in addition to oral hydroxychloroquine, the usual dosage is:
azathioprine 2 to 3 mg/kg (maximum 150 mg) 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).
If mycophenolate is indicated for a child or adolescent with SLE, in addition to oral hydroxychloroquine, the usual dosage is:
1mycophenolate mofetil 800 to 1200 mg/m2 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).
If methotrexate is indicated for a child or adolescent with SLE, in addition to oral hydroxychloroquine, the usual dosage is:
1methotrexate 15 mg/m2 (maximum 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).
If rituximab is indicated for a child or adolescent with SLE, in addition to oral hydroxychloroquine, the usual dosage isWatson, 2015:
1rituximab 375 mg/m2 intravenously once a week for up to 4 doses rituximab rituximab rituximab
OR
1rituximab 750 mg/m2 (maximum 1 g) intravenously, as a single dose; repeat dose after 2 weeks. rituximab rituximab rituximab
For additional considerations specific to rituximab use, see Specific considerations for use of biological or targeted-synthetic disease-modifying antirheumatic drugs (b/tsDMARDs).
Cyclophosphamide can induce gonadal failure; the immunomodulatory drugs discussed above are preferable for both male and female children and adolescents. Testicular function is more likely to be affected by cyclophosphamide than ovarian function. The peripubertal ovary is more resistant to cyclophosphamide-induced failure than the adult ovary.