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IV cyclophosphamide bodes well for neuropsychiatric SLE

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Doctors may have found an effective treatment for one of the worst complications of systemic lupus erythematosus (SLE), if findings from an initial trial are correct. Theirs is a larger and longer term comparative study than many others and one of the few controlled trials in SLE.

Intravenous (IV) cyclophosphamide (Cy) was more effective than IV methylprednisolone (MP) for patients with acute severe neuropsychiatric SLE expressing seizures, peripheral neuropathy, optic neuritis, and brainstem disease. Treatment with Cy failed in just one patient out of 19 compared with seven of 13 given MP.

Thirty two patients were studied out of 38 recruited from two tertiary referral centres in Mexico City. All were aged 18 years or over and had incident neuropsychiatric SLE of 15 days or less or refractory seizures. After randomisation all received induction treatment of MP 1 g daily for three days followed by either Cy (0.75 g/m2 monthly for a year, then quarterly for another year) or MP (1 g daily for three days, monthly for four months, bimonthly for six months, then quarterly for a year). Patients were followed up each month. Improvement or deterioration was judged as a 20% difference compared with baseline measures at the fourth month after treatment started.

Neuropsychiatric complications, though the cause of much illness and death in SLE, are not well understood, nor is treatment well defined. In severe cases immunosuppressive high dose corticosteroids, IV pulse MP and Cy, and IV immunolglobulins have been used, with varying results.