Table 2

Major side effects of drugs commonly used in SLE

DrugSide effectNotes and possible protective strategies
COX, cyclo-oxygenase; IV, intravenous; NICE, National Institute of Clinical Excellence.
NSAIDsGastrointestinal irritation/bleedingAvoid using NSAIDs in patients with history of gastrointestinal bleed
Co-use gastroprotective agents, for example, proton pump inhibitors
Follow recent NICE guidelines regarding COX-2 specific drugs
HydroxychloroquineRetinopathy (rare)Baseline assessment
Retinopathy, usually reversible on stopping drug (regular monitoring may be beneficial)
CorticosteroidsOsteoporosisBone density scan quantification. Co-prescribe calcium/vitamin D supplements for most patients on long term steroids. Some may need oral/IV bisphosphonates
HypertensionMonitor regularly and treat with standard antihypertensive agents
Glucose intoleranceChecking urine for glucose is usually sufficient for monitoring
Susceptibility to infectionParticularly if also on azathioprine or cyclophosphamide
Low threshold for aggressive antimicrobial therapy
AzathioprineBone marrow toxicityInitially weekly and subsequently 4–6 weekly full blood count once stable dose
Usually reversible when drug discontinued
Avoid co-prescribing drugs which potentiate effect, for example, allopurinol. Increased risk of leucopenia with captopril
Liver dysfunctionMonitor liver function tests as per full blood count
Effect usually reversible when drug discontinued
CyclophosphamideBone marrow toxicityNadir in white count occurs 10 days after infusion. This value can be used to deduce whether next dose can be safely given or needs to be reduced
Haemorrhagic cystitisGood hydration (IV fluids if giving IV cyclophosphamide)
Mesna is protective: oral or IV
Increased risk of malignancyEspecially bladder carcinoma or lymphoma
Seen less often with IV pulsed treatment presumably as cumulative dose tends to be less than oral therapy.
Infertility/amenorrhoeaParticularly in women over 30 years
NauseaPowerful antiemetics such as granisetron often necessary