Medication	Funding	Patient selection	Recommended dose and treatment strategy	Response rate	Time to response	Toxicities
Azathioprine 64	General schedule on the PBS PHARMAC‐funded	No access to TPO‐RAs or rituximab, and patients who have expressed a preference to avoid surgery Acceptable safety profile in pregnancy 14 , 65	1–3 mg/kg per day (50–200 mg daily) Concomitant steroids are usually required when starting treatment	40–60%	3–4 months	Perform TPMT assay to confirm normal enzyme clearance Interaction with allopurinol Nausea, infection and neutropenia
Mycophenolate mofetil 66	General schedule on the PBS PHARMAC‐funded	No access to TPO‐RAs or rituximab, and patients who have expressed a preference to avoid surgery	Start at 250 mg twice a day, double the dose every 2 weeks until response or as tolerated May start higher or increase sooner if less concerned about gastrointestinal side effects Maximum dose 3000 mg per day	50–60%	50% of patients respond by 4 weeks	Monitor FBC carefully for cytopenias Diarrhoea is common Other toxicities: neutropenia, anaemia and viral infections Small increased risk of malignancy and progressive multifocal leukoencephalopathy with prolonged use
Hydroxychloroquine 67	Streamlined authority; PBS reimbursement as “autoimmune disease” PHARMAC‐funded	ANA‐positive and unable to access TPO‐RAs or rituximab Use with caution in patients with pre‐existing heart disease or risk of retinopathy	200 mg twice a day Concomitant steroids are usually required when starting	60%	2–3 months	Most common adverse effects include gastrointestinal symptoms and/or rash Rare, but significant adverse effects, include arrhythmias, cardiomyopathy and retinopathy Long term users should have annual ophthalmology review
Danazol 68	No reimbursement from PBS In Australia, it needs SAS application to import from international supply No longer generally available in New Zealand	Consider in men with no history of prostate cancer, who do not have a history of thromboembolic disease, who have previously responded to corticosteroids, and who are unable to access rituximab or TPO‐RAs	200 mg given two to four times a day. Dose can be tapered once response is obtained	40–50%	3–6 months	Increased risk of thrombosis and liver toxicity Androgenic side effects PSA should be checked in men before use
Dapsone 69	General schedule on the PBS PHARMAC‐funded	No access to rituximab or TPO‐RAs Comorbidities such as thromboembolic disease may make use of TPO‐RAs less desirable Additional benefit as Pneumocystis jiroveci pneumonia prophylaxis for patients who may be at increased risk from immunosuppression	100 mg/day	50%	3 weeks	G6PD assay before commencement Monitor haemolysis markers (haptoglobin, reticulocyte count and LDH) to guide effectiveness and toxicity. Ideally, target a small amount of subclinical haemolysis Severe oxidative haemolysis especially in patients with G6PD deficiency Other side effects include abdominal distension, anorexia, and methaemoglobinaemia, which manifests as cyanosis and breathlessness
Ciclosporin 70	General schedule on the PBS PHARMAC‐funded	No access to TPO‐RAs or rituximab, and patients who have expressed a preference to avoid surgery Acceptable safety profile in pregnancy 71	3–5 mg/kg per day in two divided doses (75–300 mg twice a day) Concomitant steroids are usually required when starting	40–60%	1–3 months	Common side effects include hypertension, renal impairment, headaches and infections Trough levels can be monitored but consult with local reference ranges to minimise toxicity

ANA = antinuclear antibodies; FBC = full blood count; G6PD = glucose‐6‐phosphate dehydrogenase; LDH = lactate dehydrogenase; PBS = Pharmaceutical Benefits Scheme (Australia); PHARMAC = Pharmaceutical Management Agency (New Zealand); PSA = prostate‐specific antigen; SAS = Special Access Scheme; TPMT = thiopurine methyltransferase; TPO‐RAs = thrombopoietin receptor agonists.