Pulse Cyclophosphamide Therapy For Lupus Nephritis
  1. Administer pulse IV Cyclophosphamide (IVCY) monthly for 6 months. In patients with extremely aggressive disease, if the WBC is within normal range before each infusion, can infuse IVCY every 3 weeks.
  2. Then infuse IVCY quarterly for one year beyond remission (Inactive urine sediment, proteinuria <1g/d, and little or no extrarenal lupus activity). Can extend the interval between infusions more gradually for patients with persistently severe renal +/or extrarenal SLE.
  3. Initial IVCY dose is 0.75g/m2 (0.5g/m2 if GFR< 1/3 normal). Administer in 150cc NS IV over 30 to 60 minutes.
  4. Adjust subsequent doses to maximum dose of 1g/m2 unless WBC nadir at 10 to 14 days after IVCY falls below 1500/microliter.
  5. Induce dilute diuresis with IV fluids (e.g. 2L at 250 ml/hr). Continue large volume oral intake and frequent voiding (every 2 hours) for 24 hours after IVCY.
  6. Initiate continuous bladder irrigation by three-way Foley catheter for patients unlikely to achieve a dilute diuresis (because of sever nephrotic syndrome or renal failure).
  7. Give Mesna (each dose 20% of IVCY dose) IV or PO before and 2, 4 and 6 hours after IVCY.
  8. Give antiemetic: Dexamethasone 10mg (single dose) plus serotonin receptor antagonists (Granisetron (Kytril) 1 to 2mg q 12hr or Ondansetron 8mg q 4-8hr) for 24 hours. Occaisionally, patients require antiemetic for an additional 1 to 2 days.
  9. Prednisone dose (NIH studies): 0.5mg/kg/day for 4 weeks followed by tapering (5mg qod each week) to 0.25mg/kg qod.