Information

Information for Medical Professionals

The 'St Thomas' low-dose Cyclophosphamide' Regime

For decades now, the standard early treatment for severe lupus, especially lupus kidney disease (nephritis) has been a combination of steroids and drugs, which suppress the overactive immune system. For years the two most commonly used "immunosuppressives" have been Azathioprine ("Imuran") - for less severe cases - and Cyclophosphamide ("cyclo" or "endoxan") - the stronger drug.

Some 30 years ago, doctors at the National Institutes of Health (NIH) in Washington reported a formula for giving cyclo by injection as an intravenous drip or 'pulse', usually monthly. The 'NIH regime' as it is known has become the standard formula for giving Cyclophosphamide and is used around the world. It has contributed hugely to the improved outcome in severe lupus, especially lupus nephritis. Unfortunately, Cyclophosphamide, especially in the high doses used in the NIH regime, is a toxic drug, and side effects were common and serious. Up to 30% of patients developed infections - including the painful virus infections Herpes Zoster or Shingles. Even more serious, a significant number of women became infertile.

In 1985, at the start of the combined renal clinic at St Thomas' Hospital, I decided to modify the regime using a more conservative dosage - fortnightly doses initially followed by monthly pulses using roughly half the total Cyclophosphamide dose. We were very impressed with the outcome: clinically similar results but with far fewer side effects - indeed in our analysis of our first 1000 pulses, there were no cases of infertility.

Pioneering this work at St Thomas' was Dr David D'Cruz. One of our visiting research fellows, Dr Fred Houssiau, now Professor of Rheumatology in Brussels, decided with Dr D'Cruz and others to set up a European - wide study of lupus nephritis treatment, using the "St Thomas' regime".

The results published some years ago, were striking - similar benefits to the NIH regime but with far, far fewer side effects. The data was presented by Prof Houssiau at the New York International Lupus conference and at the Ten Topics meeting at St Thomas' as well as the American College of Rheumatology meetings.

Such a study may not hit the newspaper headlines as an 'advance' in lupus treatment. Yet for lupus patients and their doctors, the implications are considerable. Clearly, the European wide study will prove a turning point in the management of lupus nephritis, just as the NIH studies did 30 years ago.

More recently a relatively new agent mycophenolate mofetil (MMF) is proving to be a major advance. Ongoing research is showing that it's as effective as intravenous cyclophosphamide but with less toxicity and avoids the need for drips. This is very promising treatment.

Updated 11/2008

Home > Information > Information for Medical Professionals > low-dose Cyclophosphomide' Regime