Corticosteroids - Systemic

Drug	Dosage	Remarks
Betamethasone	0.5-9 mg PO 24 hourly in divided doses or Betamethasone dipropionate 5 mg/Betamethasone sodium phosphate 2 mg per/mL¹: 2 mL IM, repeat as needed	Adverse Reactions GI effect (gastritis); Musculoskeletal effects (muscle weakness, muscle wasting, osteoporosis, vertebral compression and long bone fractures); Metabolic effects (electrolyte imbalances, hyperglycemia, dyslipidemia); CNS effects (vertigo, headache); Ophthalmologic effects (glaucoma, increased intraocular pressure, exophthalmos); Dermatologic effects (acne, facial erythema, petechiae, increased sweating); Other effects (weight gain, pain, weakness, increased susceptibility to infection, impaired wound healing, increased BP) Special Instructions Take with food Use with caution in patients with active infection, increased stress, DM, hypothyroidism, cirrhosis
Cortisone acetate	25-300 mg PO 24 hourly or on alternate days
Dexamethasone	0.75-9 mg/day PO in 2-4 divided doses or 0.5-9 mg/day IM/IV in 2-4 divided doses
Hydrocortisone	20-240 mg/day PO in 2-4 divided doses or 100-500 mg IM/IV over 30 seconds-10 minutes May be repeated 2-6 hourly
Methylprednisolone	4-48 mg PO 24 hourly or 80-120 mg IM 24 hourly for 1-3 days followed by oral corticosteroid extended taper or 4-120 mg IM 24 hourly or 20-60 mg intralesionally per treatment session For large lesions, 20-40 mg distributed by repeated local injection may be necessary; usually 1-4 injections are employed Severe/organ-threatening disease: 125-1,000 mg/day IV pulses for 1-3 days Continue with Prednisone 0.5-0.7 mg/kg/day PO with tapering of dose High-dose therapy: 30 mg/kg/dose IV over at least 30 minutes 4-6 hourly for 48-72 hours
Prednisolone	5-60 mg PO 24 hourly or in divided doses
Prednisone	Mild to moderate disease: Start with ≤0.5 mg/kg/day PO with gradual tapering All circumstances: Avoid starting with 1 mg/kg/day PO Maintenance dose: ≤7.5 mg/day or Initial dose: 5-60 mg PO 24 hourly Continue or adjust initial dosage until a satisfactory response is noted
Triamcinolone	60 mg PO 24 hourly Maintenance dose: 3-30 mg/day Initial dose: 60 mg IM 24 hourly Titrate according to patient’s response Usual dose range: 40-80 mg IM 24 hourly or 1 mg intradermally per injection site

¹Combination product is available. Please see the latest MIMS for specific formulations and prescribing information

Corticosteroids - Topical

Drug	Available Strength	Dosage	Remarks
Very Potent
Clobetasol propionate	0.05% cream, gel, ointment, scalp application	Apply 12-24 hourly	Application Once-twice daily applications are recommended for most agents. More frequent administration may be necessary for palms or soles of feet Every other day or weekend application has been used to treat chronic conditions Length of cream/ointment squeezed from tube can be measured by finger tip unit (FTU) which is tip of adult index finger to 1st crease 1 FTU (approximately 500 mg) is sufficient to cover 2x the size of flat adult hand Recommended use of very high potency agent is for 1-2 weeks (max 3 weeks) following with weaker potency preparations as the condition improves Adverse Reactions The more potent the agent, the more chance of adverse reactions Local effects: Thinning of skin which may be restored after stopping treatment, worsening of underlying infection, contact dermatitis, acne at site of application, hypopigmentation which may be reversible, irreversible telangiectasia and striae atrophica Systemic effects: Absorption through the skin can cause pituitary-adrenal-axis suppression, growth retardation, hypertension and Cushing’s syndrome Absorption is increased by thin and/or raw skin, intertriginous areas or occlusion Absorption is more likely when used over very large areas Special Instructions Very potent agents should not be used in patients <1 year of age Potent agents will rarely cause side effects if used for <3 months (except if used on face or intertriginous areas) Intermittent therapy is usually preferable to long-term continuous therapy
Potent
Beclometasone dipropionate	0.025% cream	Apply 24 hourly
Betamethasone	0.1% cream	Apply 8-12 hourly
Betamethasone valerate¹	0.1% cream, gel, lotion, ointment, solution	Apply 8-24 hourly
Desoximetasone	0.25% cream	Apply 6-24 hourly
Diflucortolone valerate	0.1% fatty ointment	Apply 8-12 hourly, then 24 hourly once improved
Fluocinolone acetonide	0.01% cream, lotion, ointment	Apply 8-24 hourly
	0.2% cream	Apply 8-12 hourly
	0.025% cream, gel, ointment	Apply 8-24 hourly
Fluocinonide	0.05% cream, ointment	Apply 8-12 hourly
Fluticasone propionate	0.05% cream	Apply 12-24 hourly

¹Combination with Fusidic acid is available. Please see the latest MIMS for specific formulations and prescribing information.

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Drug

Dosage

Remarks

Chloroquine

As Chloroquine phosphate: 250 mg (150 mg base) PO 24 hourly or 12 hourly for 1-2 weeks
Maintenance dose: 250 mg (150 mg base) PO 24 hourly

Adverse Reactions

GI effects (nausea/vomiting); Dermatologic effects (pruritus, urticaria); Other effects (headache, ECG changes, abnormal LFTs); Rarely hematologic reactions
Serious adverse effects: Retinal toxicity which may cause irreversible retinopathy, hearing defect, proteinuria, skeletal muscle myopathy or neuropathy, increased risk of hemolytic anemia, acute extrapyramidal disorders, suicidal behavior

Special Instructions

Use with caution in patients with hepatic and renal impairment, severe GI disease, psoriasis, myasthenia gravis, G6PDdeficiency and neurologic disorder especially epilepsy
Perform ophthalmologic exam at baseline then screen anually

Hydroxychloroquine

Initial dose: 200-400 mg PO 24 hourly or in 2 divided doses
Maintenance dose: 200-400 mg/day
Target dose: 5 mg/kg/day
Max dose: 400 mg/day

Adverse Reactions

GI effects (nausea/vomiting, diarrhea); Dermatologic effects (skin eruptions, pruritus, hyperpigmentation); Other effects (headache, prolonged QTc interval, myelosuppression, abnormal LFTs); Rarely mental changes
Serious adverse effects: Visual disturbances (eg keratopathy) which is irreversible

Special Instructions

Use with caution in patients with liver or renal dysfunction, severe GI disorders, psoriasis, myasthenia gravis, G6PD deficiency and neurologic disorder especially epilepsy
Perform ophthalmologic exam at baseline then at least every 12 months; annual screening may be deferred during the first 5 years in patients without significant risk factors, then performed annually thereafter

Emollients, Cleansers & Skin Protectives

Drug	Available Strength	Dosage	Remarks
Titanium dioxide	Cream	Apply thin coat 24 hourly or as often as needed	No photoallergic or contact properties Opacity may be cosmetically undesirable

Immunosuppressants

Drug	Dosage	Remarks
Azathioprine	Initial dose: 1-3 mg/kg/day PO in 2-3 divided doses Maintenance dose: <1-3 mg/kg/day or 50-100 mg/day	Adverse Reactions Hematologic effects (bone marrow disorders, leukopenia, thrombocytopenia, anemia); GI effects (GI disturbance, nausea, pancreatitis, cholestasis, liver damage); Other effects (increased risk of secondary infection and neoplasia, hypersensitivity reaction) Special Instructions Monitor CBC with differential and platelet, LFTs, total bilirubin, CrCl, symptoms of infection; thiopurine methyltransferase (TMPT) genotyping prior to initiation CBC with differential, AST and ALT every 2 weeks for 8 weeks, then every 2 months or more frequently if dosage alterations or other therapy changes are necessary Patient should promptly report any signs of infection, bruising or bleeding or other manifestations of bone marrow depression; most neutropenia associated with immunosuppressants occurs sporadically many months after starting therapy Contraindicated in patients with chickenpox/herpes zoster Use with caution in patients with renal or hepatic impairment
Cyclophosphamide	Organ-threatening disease: 0.75-1 g/m² BSA IV monthly for 6 months Lupus nephritis induction dose: 500 mg IV on week 0, 2, 4, 6, 8 and 10	Adverse Reactions Dermatologic effects (alopecia, skin and nails hyperpigmentation); GI effects (nausea/vomiting, mucositis); Other effects (inappropriate ADH secretion, carbohydrate metabolism disturbances, gonadal suppression, interstitial pulmonary fibrosis) Severe reactions: Anaphylactic reactions, bone marrow failure, severe immunosuppression, urotoxicity, cardiotoxicity, hyponatremia, hemorrhagic cystitis Special Instructions Verify pregnancy status prior to use in females of reproductive potential Patient should promptly report any signs of infection, bruising or bleeding or other manifestations of bone marrow depression; most neutropenia associated with immunosuppressants occurs sporadically many months after starting therapy Contraindicated in patients with impaired bone marrow function, bladder inflammation, urinary outflow obstruction and active infections Use with caution in patients with renal or hepatic impairment, DM, severe immunosuppression
Mycophenolic acid (Mycophenolate mofetil)	As Mycophenolate mofetil Organ-threatening disease or lupus nephritis induction dose: 750-1,500 mg PO 12 hourly (daily dose of up to 3 g) Mild to moderate disease or maintenance dose of lupus nephritis: 500-1,000 mg PO 12 hourly As Mycophenolate sodium Induction and maintenance dose of lupus nephritis: 720 mg PO 12 hourly	Adverse Reactions CV effects (hypertension, hypotension, peripheral edema, chest pain, tachycardia); CNS effects (pain, headache, insomnia, dizziness, anxiety); GI effects (abdominal pain, diarrhea, nausea/vomiting); Metabolic effects (hyperglycemia, hypercholesterolemia, hypomagnesemia, hypokalemia, hypocalcemia, hyperkalemia); Other effects (rash, fever, abnormal CBC) Special Instructions Use with caution in patients with severe renal impairment, active GI disorders, and in those with intrauterine devices (due to increased risk of infection) Risk of infection and activation of latent viral infection is increased; neutropenia (including severe neutropenia) may occur, requiring dose reduction or interruption of treatment
Biologic Agents
Anifrolumab	SLE 300 mg IV infusion over a 30-minute period every 4 weeks Transition from SC to IV: Administer first IV infusion approximately 3-4 weeks after the last SC injection or 120 mg SC once weekly Transition from IV to SC: Administer first SC injection approximately 2 weeks after the last IV infusion	Adverse Reactions Respiratory effects (nasopharyngitis, upper respiratory tract infections, bronchitis, cough); Other effects (infusion-related reactions, herpes zoster) Serious hypersensitivity reactions including angioedema and anaphylaxis have been reported Special Instructions Avoid initiating treatment during an active infection and avoid use of live or live-attenuated vaccines Before prescribing Anifrolumab, consider the individual benefit-risk in patients with known risk factors for malignancy Contraindicated in patients with a history of anaphylaxis with Anifrolumab-fnia
Belimumab	SLE 10 mg/kg IV infused over 1 hour on days 0, 14 and 28 then every 4 weeks thereafter or 200 mg SC once weekly Transition from IV to SC: Administer first SC injection 1-4 weeks after the last IV dose Lupus Nephritis 10 mg/kg IV infused over 1 hour every 2 weeks for the first 3 doses then every 4 weeks thereafter or Initial therapy with Belimumab: 400 mg (two 200 mg injections) SC once weekly for 4 doses, then 200 mg SC once weekly thereafter Continuing therapy with Belimumab: 200 mg SC once weekly Transition from IV to SC: May transition any time after receipt of the first 2 IV doses Administer first SC dose of 200 mg 1-2 weeks after the last IV dose	Adverse Reactions CNS effect (migraine); GI effects (nausea, diarrhea); Psychological effects (suicide/suicidal ideation, depression); Dermatologic effects (rash, urticaria, pruritus, hypersensitivity reaction), Respiratory effects (upper respiratory tract infection, bronchitis); Other effects (fever, leukopenia, injection site reactions, urinary tract infection) Special Instructions Not recommended for use in patients with severe active CNS lupus, HIV, history of/currently with hepatitis B/C, hypogammaglobulinemia or IgA deficiency, history of major organ transplant, hematopoietic stem cell/marrow transplant, or renal transplant Patient's condition should be evaluated continuously Should not be administered as an IV bolus
Obinutuzumab	Lupus nephritis: 1,000 mg IV once, then 1,000 mg IV at week 2, 24, and 26, followed by 1,000 mg IV every 6 months	Adverse Reactions CNS effects (migraine, headache, insomnia); GI effects (nausea, diarrhea, constipation); Dermatologic effects (rash, urticaria, pruritus); Respiratory effects (bronchospasm, cough); Other effects (fever, leukopenia, infusion-related reactions) Special Instructions Contraindicated in patients with history of significant adverse event(s) associated with previous use Use with caution in patients with cardiac disease, hypertension, infection, pulmonary disease, women who may become pregnant
Calcineurin Inhibitors
Tacrolimus	Lupus nephritis: 3 mg PO 24 hourly or 0.0025-0.05 mg/kg/dose PO 12 hourly Adjust dose to target serum Tacrolimus concentration of 4-6 ng/mL	Adverse Reactions CNS effects (headache, tremor, paresthesia, hearing loss, visual disturbances, peripheral neuropathies, convulsions); CV effects (hypertension, cardiac arrest, heart failure, ventricular arrhythmias, palpitations, cardiomyopathies); GI effects (nausea, diarrhea, dyspepsia, constipation, GI hemorrhage and ulceration); Respiratory effects (dyspnea, parenchymal lung disorders, pleural effusions, cough, nasal congestion, pharyngitis, asthma); Dermatologic effects (acne, alopecia, skin rashes, pruritus); Musculoskeletal effects (muscle cramps, asthenia, arthralgia); Hematologic effects (pancytopenia, agranulocytosis, coagulation disorders); Other effects (renal impairment, hyperlipidemia, febrile disorders, edema, liver dysfunction) Potentially fatal: Polyoma virus infections, GI perforation Special Instructions Use with caution in patients with renal impairment and hepatic impairment, patient with risk factors for QT prolongation Monitor for infections, ECG, BP, FBS, hematological, neurological (including visual) and coagulation parameters, electrolytes, hepatic and renal function, whole blood Tacrolimus trough concentration (especially during diarrhea episodes)
Voclosporin	Lupus nephritis: 23.7 mg PO 12 hourly	Adverse Reactions GI effects (diarrhea, abdominal pain, dyspepsia, mouth ulceration); Renal effects (decreased GFR, renal impairment, acute kidney injury); Other effects (hypertension, headache, anemia, cough, UTI, alopecia, fatigue, tremor, decreased appetite) Special Instructions Establish an accurate baseline estimated GFR (eGFR) and check BP prior to starting Voclosporin; modify dose based on eGFR Contraindicated in patients with known serious or severe hypersensitivity reaction to Voclosporin or any of its excipients, concomitantly using Ketoconazole, Itraconazole or Clarithromycin Use with caution in patients with risk factors for hyperkalemia or QT prolongation Monitor for neurologic abnormalities, drug interactions, renal function, serum potassium levels Consider discontinuing therapy if without therapeutic benefit by 24 weeks Avoid live vaccines

Disclaimer

All dosage recommendations are for non-pregnant and non-breastfeeding women and non-elderly adults with normal renal and hepatic function unless otherwise stated.
Not all products are available or approved for above use in all countries.
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs.
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.

Systemic Lupus Erythematosus Drug Summary