Table 1.
Treatment protocol
| Agent | Dose | |
|---|---|---|
| Cytotoxic therapy | ||
| Day 0 | Rituximab | 1 g |
| Cyclophosphamide i.v. | 10 mg/kg (maximum 750 mg) | |
| Week 2 | Rituximab | 1 g |
| Cyclophosphamide i.v. | 10 mg/kg (max. 750 mg) | |
| Weeks 4, 6, 8 and 10 | Cyclophosphamide i.v. | 500 mg × 4 |
| Corticosteroid taper | ||
| Week 1 | Oral prednisolone | 1 mg/kg/day (maximum 60 mg) |
| Week 2 | 25% reduction | 45 mg |
| Week 3 | 33% reduction | 30 mg |
| Week 4 | 33% reduction | 20 mg |
| Week 6 | 25% reduction | 15 mg |
| Week 12 | Minimum 12.5 mg | |
| Week 20 | 10 mg | |
| Maintenance therapy | ||
| From Week 12 | Azathioprine | 1–2 mg/kg/day (adjusted for TPMT levels) |
| Mycophenolate mofetil (if intolerant) | 1–2 g/day (targeted to trough levels of 1.2–2.4 mg/L) | |
| Prophylactic therapy | ||
| PJP prophylaxis | Co-trimoxazole 480 mg/day | |
| Pentamidine nebulizer 300 mg/month (if intolerant) | ||
| Peptic ulcer prophylaxis | Proton-pump inhibition | |
| Bone prophylaxis | Vitamin D and calcium supplementation | |
| Latent TB prophylaxis (in those from high-risk areas) | Isoniazid 150 mg/day and pyridoxine 50 mg/week | |
i.v., intravenous; TPMT, thiopurine methyltransferase enzyme activity; PJP, Pneumocystis jiroveci pneumonia; TB, tuberculosis.