Question

Does thalidomide have a role in the treatment of resistant cases of discoid lupus? If so, what is its appropriate dosing and monitoring?

Ahmed El-Rafie, MB, BCh, MSC, MRCP

Response from John J. Cush, MD

Thalidomide has been used as an inhibitor of tumor necrosis factor (TNF)-alpha, albeit a weak one, and has been advocated for the treatment of rheumatoid arthritis, lupus skin disease (including discoid lupus erythematosus),[1,2] and vasculitic skin diseases[3] in which it is thought that the TNF effects on vascular endothelium, intercellular adhesion molecule-1 expression, and keratinocytes mediate manifestations of disease. The commonly used dose is 100 mg/day (range, 25-200 mg/day); the dose may be adjusted downward once cutaneous improvement has been realized. The patient should be monitored closely for adverse effects (eg, drowsiness, vertigo, neuropathy/paraesthesia, constipation, weight gain) and teratogenic precautions must be used (double contraceptive measures, frequent beta-human chorionic gonadotropin screens) in female patients of child-bearing age.

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