Systemic lupus erythematosus
DMARDs.
200-400mg daily, daily maximum dose to be based on ideal body-weight; maximum 6.5mg/kg per day.
200-400mg daily, daily maximum dose to be based on ideal body-weight; maximum 6.5mg/kg per day.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Initially up to 2.5mg/kg daily in divided doses, adjusted according to response, rarely more than 3mg/kg daily; maintenance 1-3mg/kg daily, consider withdrawal if no improvement within 3 months.
Initially up to 2.5mg/kg daily in divided doses, adjusted according to response, rarely more than 3mg/kg daily; maintenance 1-3mg/kg daily, consider withdrawal if no improvement within 3 months.
Dose advised by specialists.
Biologics and cyclophosphamide.
For intravenous infusion; 1g, then 1g after 2 weeks, consult product literature for information on retreatment.
For intravenous infusion; 1g, then 1g after 2 weeks, consult product literature for information on retreatment.
Refer to national guidance (SMC) for Belimumab approved indication and restriction.
Refer to product literature.
Refer to product literature.
Refer to product literature.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Prescribing Notes:
- Risks/benefits of disease modifying antirheumatic drugs (DMARDs) should be discussed with patients before commencing using a written information sheet available from Versus Arthritis.
- DMARDs are appropriate for shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice.
- The MHRA has received reports of prescription and dispensing errors for methotrexate that have resulted in serious and fatal adverse reactions. Methotrexate tablets should be prescribed in 2.5mg strength only. The 10mg strength should not be used since they may be confused with the 2.5mg tablets.
- Patients who have a partial response to or intolerance of oral methotrexate may be switched to subcutaneous methotrexate under the guidance of a rheumatologist.
- Providing monitoring procedure is followed, NSAIDs may be prescribed with methotrexate.
- Subcutaneous methotrexate is available in a variety of brands and formulations. The brand used currently (April 2022) in rheumatology is Metoject pre-filled pen.
- Folic acid 5mg should be prescribed weekly, 24 hours after methotrexate to reduce toxicity. This can be increased to daily (apart from day of methotrexate) if side effects are troublesome. This option could be considered routinely to avoid the risk of nausea / mouth ulcers and the patient stopping the drug.
- The use of oral methotrexate for non-malignant conditions such as rheumatoid arthritis has been highlighted nationally as a potential risk for fatal medication errors. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice see MHRA Drug Safety Update September 2020.
History Notes
03/05/2023
Updates to formulary content for belimumab, ERFC March 23.
08/12/2022
Updates to formulary content for belimumab, ERWG Nov 22
18/05/2022
East Region Formulary content agreed.
DMARDs.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
Dose advised by specialists.
Dose advised by specialists.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
Folic acid may be prescribed for patients with evidence of intolerance to methotrexate Folic acid oral solution should only be used when patients cannot tolerate or use solid formulations.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
Biologics and cyclophosphamide.
Prescribe rituximab by brand name.
As per specialist
As per specialist
For dose, refer to BNF for children.
For dose, refer to BNF for children.
For dose, refer to BNF for children.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Dose advised by specialists.
Prescribing Notes:
- Initial management of Systemic lupus erythematosus with systemic corticosteroids and DMARDs is directed by a specialist paediatric rheumatology prescriber experienced in the management of the condition, use is in line with relevant local or national guidance.
- Risks/benefits of disease modifying antirheumatic drugs (DMARDs) should be discussed with patients before commencing using a written information sheet available from Versus Arthritis.
- DMARDs are appropriate for shared care agreements to facilitate the seamless transfer of individual patient care from secondary care to general practice.
- The MHRA has received reports of prescription and dispensing errors for methotrexate that have resulted in serious and fatal adverse reactions. Methotrexate tablets should be prescribed in 2.5mg strength only. The 10mg strength should not be used since they may be confused with the 2.5mg tablets.
- The use of oral methotrexate for non-malignant conditions such as rheumatoid arthritis has been highlighted nationally as a potential risk for fatal medication errors. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice, see MHRA Drug Safety Update September 2020.
- Patients who have a partial response to or intolerance of oral methotrexate may be switched to subcutaneous methotrexate under the guidance of a rheumatologist.
- Subcutaneous methotrexate should only be given by individuals trainer to administer methotrexate completely.
- Methotrexate is the first choice in the majority of rheumatic diseases but in certain conditions other agents may be preferred first e.g. lupus
- Providing monitoring procedure is followed, NSAIDs may be prescribed with methotrexate. However, the need for NSAID therapy should be reviewed once methotrexate becomes effective.
- Calcium folinate (folinic acid) 15mg orally or by injection may be an alternative for children who are unwilling to take folic acid due to gastro-intestinal intolerance or its unpalatability.
- All children must be adequately monitored. Refer to SPARN guidelines/BNFc/SPC for full details for the medication in question.
- Belimumab is approved for add-on therapy in adolescents aged 5 to 18 years with active, autoantibody-positive systemic lupus erythematosus (SLE) with a high degree of disease activity despite standard therapy. Restricted to use in people with evidence for at least one marker of serological disease activity (low complement, positive anti-dsDNA) and a Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) score greater than or = to 10.
History Notes
08/09/2025
New formulary content. Agreed ERFC May 2025.