Medication
Naproxen,
ibuprofen,
indomethacin,
sulindac, celecoxib
Indication
First line for JIA
Mechanism
COX-1, 2
inhibition
Dose
Variable
Caveats
Gastritis,
hepatotoxicity, renal
toxicity, coagulation
suppression
Methotrexate
JIA, JDM, SS, SLE
0.5-1mg/kg/dose
(up to 20mg PO
or 25mg SQ)
Qweek
GI (pain, N/V,
ulceration),
hepatotoxicity
(fibrosis),
malignancy
Sulfasalazine
ERAs, JIA
Anti-metabolite
(folate analog).
Suppress
inflammatory
cytokine
production, inhibits
DHFR, inhibits
lymphocyte
proliferation in
high doses.
Anti-bacterial/antiinflammatory.
Unclear.
30-50mg/kg/day
divided BIDTID
Hydroxychloroquine
SLE, other
connective tissue dz
6mg/kg/day up
to 400mg PO
daily
Methylprednisolone,
prednisone,
prednisolone
When you need
quick, effective, antiinflammatory effect
(used in virtually all
inflammatory
conditions)
Multiple. Inhibits
phospholipid
function and binds
DNA
Induces
transcription of
anti-inflam and
immunomodulatory
genes. Suppress
inflammatory
cytokine
production. At high
doses, IV, it blocks
cell signaling and
depletes
lymphocyte
numbers.
Colchicine
Behcet’s disease,
Familial
Mediterranean Fever
SJIA
Inhibits
cytoskeletal
transport
Inhibits cytokine
secretions and T
cell proliferation
0.6 mg=1 tab
given qd or bid
Watch for sulfa
allergies; GI
toxicity; monitor
quantitative Ig
Retinal
hyperpigmentation
(retinal exam 1-2
times/year)
Hypertension (esp.
w/ pulses); atrophy
of skin, impaired
wound healing;
body fluid retention,
decreased body
growth,
hypernatremia,
hypokalemia ;
peptic ulcer disease;
liver function tests
abnormal (mild); at
risk of infection;
muscle weakness;
osteopenia/porosis;
glaucoma, cataracts;
depression,
euphoria
GI upset: diarrhea,
abd pain, nausea
SLE (severe LN or
CNS involvement);
severe vasculitis
Alkylating agent,
depletes T and B
cells
1mg/kg/day,
10mg/kg/dose
Q2weeks, 500-
Extremely
teratogenic, can
cause peripheral
neuropathy
Hemorrhagic
cystitis (void Q2hrs
w/ infusion,
Glucocorticoids
DMARDs
NSAIDs
COMMONLY USED MEDICATIONS
Thalidomide
Cytot
oxic
Agen
ts
Cyclophosphamide
Low dose (510mg/day),
medium dose (12mg/kg/day),
high dose
(30mg/kg/dose
pulses (up to 1g)
Biologics
750+mg/m2/dose
Q4-8weeks
Mycophenylate
mofetil (Cellcept,
Myfortic)
SLE class III,IV, V
LN; JDMS; MCTD
Azathioprine
Hematologic SLE,
SLE
Cyclosporine
Membranous LN;
JDMS
TNF alpha
inhibitors:
etanercept,
infliximab,
adalimumab
Spondyloarthropathy,
JIA, uveitis when
first/second line
meds ineffective
IL-1 receptor
antagonist (IL-1ra) :
anakinra (Kineret)
SJIA,
NOMID/CINCA
Anti-soluble IL-6
receptor
(anti-sIL-6R)Tocilizumab
SJIA
Inhibits de novo
synthesis of
guanine (T/B cells
cannot salvage).
Inhibits T and B
cells.
Purine analog;
metabolized to 6MP. Inhibits T cells
Goal dose
600mg/m2 BID;
may need to start
at lower dose
and titrate up as
tolerated
0.52.5mg/kg/day
Calcineurin
inhibitor
(translocation of
NF-AT). Blocks
transcription of T
cell genes.
Competitively
inhibit TNF alpha
receptors- TNF
causes
inflammation , T
and B cell
signaling, and T
cell proliferation.
3-5mkg/kg/day
A recombinant
form of the natural
IL-1 receptor
antagonist, it
blocks cell
signaling by
IL1alpha and beta.
Humanized
monoclonal
antibody that
blocks cell
signaling by the IL6 and IL-6 receptor
complex.
1-3 mg/kg/day
Variable
MESNA); must be
dose adjusted for
renal insufficiency;
fertility concerns;
pancytopenia;
malignancy
GI toxicity
(diarrhea);
pancytopenia
Check TMPT
enzyme to make
sure med can be
metabolized;
pancytopenia. Can
check 6-MMPN and
6-TGN levels)
Grapefruit juice
incr. levels;
pancytopenia, can
check levels, it is
renal toxic
CHF (esp.
infliximab); must
check PPD prior to
starting med (TB
activation);
malignancy;
demyelinating dz;
development of
ANA/autoimmunity
Immunosuppression
This is a very
painful injection.
CTLa-4 Ig
(abatacept/Orencia)
JIA, SLE
Rituximab
SLE, JIA, JDMS,
TTP
a fully human
soluble fusion
protein, which
works by
selectively
modulating a costimulatory signal
which is required
for full T-cell
activation.
Anti-CD20 Ab;
targets pre-B and
mature B cells, but
not plasma nor
stem cells.
NSAIDS
Naprosyn *  10 mg/kg/dose given bid
Ibuprofen *  40-50 mg/kg/day given tid-qid
Tolmetin * 30 mg/kg/day given bid-tid
Indomethacin 2-3 mg/kg/day given bid- qid
10 mg/kg/dose
up to 500 mg IV
every 2-4 weeks
375mg/m2
Qweek x 4 doses
or 500mg/m2
Q2weeks x 2
doses
Try to immunize
with pneumococcal
and meningococcal
vaccines prior to
starting med; can be
hypotensive w/
infusion, must run
slowly, esp. first
dose
* FDA approved for children
 available in suspension
• Need to have 4-6 week trial of
NSAID for JIA
CYCLOPHOSPHAMIDE (Cytoxan)
• The dosing, route of administration and frequency is determined individually based on
disease entity.
o 1-2 mg/kg/day po daily for severe vasculitis such as Wegener’s
o 10 mg/kg/dose IV q2 weeks for polyarteritis nodosa
o 500-1000 mg/m2 IV qmonth for lupus nephritis/cerebritis.
• Cytoxan breakdown products can build up in the bladder, and this can cause bladder
irritation, leading to hemorrhagic cystitis.
• If patients take Cytoxan on a daily basis, we recommend taking the Cytoxan in the morning
so that they have all day long to drink fluids for bladder protection. They should urinate
frequently to wash out the Cytoxan breakdown products that are harmful to the bladder.
• With both forms of administration (IV or oral), we ask patients to be well hydrated enough
that they urinate every 2 hours in the day (and once at night if possible) to empty the bladder.
It does not matter the amount of urine made, just that they are emptying the bladder
frequently. If they are not on a fluid restriction, we generally suggest drinking 2 to 3 liters a
day in order to maintain good UOP.
• Cytoxan is renally excreted
• Mesna is often given with Cytoxan to prevent the accumulation of toxic metabolites that can
cause bladder irritation and damage.
•
•
•
•
•
•
•
If Cytoxan is daily oral formulation, the first dose of Mesna will be 30 minutes before
Cytoxan, and the second dose will be 4 hours after Cytoxan.
For patients getting Cytoxan IV, a nadir lab draw is obtained at 10 to 14 days after the
Cytoxan infusion to monitor the WBC (ANC and ALC specifically). This helps us determine
the Cytoxan dose for the next infusion (if too low ALC/ANC, decrease dose; if too high,
increase dose). The infusion of Cytoxan reaches its peak effect at that time.
Common side effects: cytopenia, anorexia, nausea, vomiting
Occasional side effects: diarrhea, hemorrhagic cystitis, darkened areas of skin or fingernails,
fluid retention (can cause a SIADH like picture), hair loss is unusual at doses used to treat
rheumatologic disease
Rare side effects: lung irritation, congestive heart failure, secondary cancer, infertility,
depending on age and dose (often we will induce amenorrhea with Depot-Lupron to protect
the ovaries in females. We also offer sperm banking for males prior to starting Cytoxan).
Patients are told to call the pediatric rheumatologist immediately if they have: pain
when urinating, hematuria, unusual bleeding or bruising, fever (greater than 100 F), chills,
stomach or joint pain, mouth sores, persistent vomiting
No live vaccines should be given- only inactivated vaccines can be given. We do recommend
giving the inactivated flu shot.
Intravenous Cyclophosphamide Orders:
Prior to starting cyclophosphamide, check urine pregnancy test for pubertal girls and CBC-D to
ensure their counts aren’t too low (WBC, ANC, ALC).
Check vitals signs q2hours. Patients need to void q2hours. If unable to void x 2, notify MD (can
give IVF bolus or IV dose of Lasix)
Hours -2 to 0:
-15 minutes:
Hour 0:
Hours 1 to 9:
Hours 3, 6, 9:
Two hours of pre-hydration with regular IVF usually above maintenance
(1.25-1.5 x maintenance)
Mesna, first dose over 15 minutes.
Cytoxan 500-1000 mg/m2 in 100 cc NS over 1 hour
Nine hours of post-hydration with IVF above maintenance
Mesna. Mesna dose is 25% if cytoxan dose mg for mg, IV. If giving po, it
is double the IV mesna dose).
Can discharge after 9 hours, or if patient does not have nausea and drinks a lot, can be discharged
in 6 hours with last dose of Mesna given orally. This is for experienced patients only.
Often given with Solumedrol 30 mg/kg/dose with max 1 g IV during the prehydration period
(mostly for lupus patients).
Bladder Wash:
For use in patients who have <50 cc/hr of UOP (<1200 cc UOP/24 hours) secondary to renal
failure/ insufficiency and are on a fluid restriction. During these cases, the cytoxan is renally
dosed and we do not give any prehydration fluids. The Cytoxan is given and there may or may
not be any post-hydration (sometimes at a little bit of IVF for insensibles, like at 1/3
maintenance). The bladder wash is done for 36 hours, and therefore we extend the Mesna (at the
regular doses) q4hours for 9 doses total.
Bladder Wash Set-Up:
Need at bedside (order from central supply): TUR tubing, 3 L NS bags x several bags, 14-18
French 3-way Foley catheter, Foley catheter start kit, urine collection bag for drainage.
Bladder Wash:
Can give ativan for anxiolysis prior to procedure. Place foley (usually 16 French, depending on
patient’s age) 3-way foley using lidocaine gel. Do not connect TUR tubing to pump. There is no
pump used, and therefore no real “rate” as in how many cc/h. Inflate the Foley balloon to 5 cc.
Bladder wash with NS to gravity for 36 hours. Connect Foley catheter to 3L NS bag via TUR
tubing and the drainage port to gravity to the urine collection bag. During this time, it will be
impossible to measure urine output. If the continuous flow is too annoying to the patient, can
stop the continuous bladder wash, and just fill and empty bladder every 2 hours (this is nicer to
patient, but more nursing intensive). Be careful of causing urethral strictures by Foley placement.
Anti-emetics
serotonin 5-HT3 receptor antagonists:
• Ondansetron/ Zofran (0.15 mg/kg/dose) IV or PO (max dose 8 mg) 30 minutes before chemo
and q6h prn
• Graniesetron/ Kytril (10 mcg/kg) mg po (max dose 1 mg) 1 hour before chemo and q12h
• Palonosetron/ Aloxi 0.25 mg IV x 1 (lasts 72 hours, used for pts≥12 years of age and ≥40 kg)
Others:
• Aprepitant/ Emend 125 mg po on day 1, then 80 mg po qday on days 2 and 3 (used for
pts≥12 years of age and ≥40 kg) – substance p antagonist, which mediates its effect by acting
on neurokinin 1 receptor. Often used with palonosetron.
• Promethazine/ Phenergan 0.25-0.5 mg/kg/dose (max 25 mg) PO or IV q4-6h prn
• Diphenydramine/ Benadryl 1 mg/kg/dose (max 50 mg) PO or IV q4-6h prn
• Lorazepam/ Ativan 0.025-0.05 mg/kg/dose (max 2 mg) PO or IV q6h prn
Ovarian Protection in Patients Receiving Cyclophosphamide
Depot-lupron (Leuprolide acetate, a GnRH analog) 3.75 mg IM q28 days (max time limit: 28
days. Can give no later than 28 days). Induces post-menopausal state of ovarian quiescence so
that follicles are not actively dividing during cytoxan administration. Protects female fertility
during chemotherapy treatments.
 Give after day 14 of menstrual cycle (day 20-21 preferred) to ensure giving depot-lupron
during the luteal phase to achieve quicker suppression
 After first dose, patients should get menses 1-2 weeks after dose and then become
amenorheic if depot-lupron working.
 No labs to check, but follow the absence of menses to assess the adequacy of depot-lupron
dose
 If menses after 2nd dose, will need to increase depot-lupron to as high a dose as needed to
stop all menses (per endocrinology’s recommendations, can double the depot-lupron dose to







7.5mg IM and then to 11.25mg IM secondary to break-through bleeding in one patient’s
case.)
Side effects: abdominal cramps, spotting after first dose, menopausal like symptoms
If continued vaginal spotting and on high doses of depot-lupron, can obtain pelvic ultrasound
to check if uterine lining thin and suppressed. Can also obtain FSH and LH levels about 30
minutes after depot-lupron administration to see if the gonadal axis is suppressed.
Should document a negative pregnancy test prior to giving first dose.
According to online literature, there is a significant increase in risk of osteopenia/
osteoporosis in people who have been suppressed for greater than 6 months; however,
according to our endocrinology colleagues, just as long as the patient remains relatively
physically active, we can continue giving depot-lupron, even at relatively high doses
(11.25mg IM q month) indefinitely. This is, of course, assuming that the patient is taking
calcium and vitamin D supplementation and that DEXA scans are WNL.
Another option for prolonged depot-lupron use is adding norethindrone acetate 5 mg daily (at
least according to some literature sources). It is a progestin that can help protect the bones,
along with adequate calcium and vitamin D supplementation.
There are 1 month and 3 month formulations:
o 1 month: 3.75 mg, 7.5 mg, 11.25 mg
o 3 month: 11.25 mg (which is different from the 11.25 mg 1 month form)
Start with the 1 month formulation, and if tolerated, can go to the 11.25 mg IM q3 month
form.
Optimizing Bone Health In Lupus Patients And Patients on Chronic Corticosteroids
Monitoring Bone Health:
 Check iPTH, Ca, phos, Mg, alk phos, and vitamin D-25-OH, along with the rest of the lupus
birthday labs (thyroids, cholesterol, autoantibody profile), every year. Also consider
checking a Uca/cr to look at renal losses.
 Also check vitamin D-1,25-OH if patient has significant renal impairment to check on the
conversion of 25-OH to 1,25-OH, which is done by the kidney.
 Calcitriol (Rocaltrol po, Calcijex iv) is the active form of vitamin D: 1,25
dihydroxycholecalciferol
o This is the short-acting, activated form of vitamin D. Circulating 1,25 (OH) vitamin D
concentrations are affected by circulating calcium – levels are high if calcium is low
and suppressed when calcium is high.
o For patients taking synthetic calcitriol (in the form of activated vitamin D
supplements), watch for hypercalcemia and hypercalciuria. The nephrologists
definitely check a Uca/cr when patients are on calcitriol.
 Obtain an annual DXA: can correct for age, gender and ethnicity using the pediatric norm
database if DXA done at Stanford.
o There are no Stanford norms established for children <9 years but there are published
reference data.
 Ensure patient is taking enough calcium and vitamin D, both in the diet and with
supplements. Strive to meet the RDA/ DRI for Ca and vitamin D through diet and/or
supplements. Calcium is a nutrient and not a medicine. Taking MORE than recommended
may lead to renal stones or other problems.

Encourage weight bearing exercise as tolerated
Calcium:
 Usual form : calcium carbonate (TUMS, Viactiv, Oscal-D, etc)
o Must be taken AFTER a meal (when stomach fluid is acidic) for the best calcium
absorption: max absorption is 500 mg/dose
o In renal failure patients, take with food as a phosphate binder, not as a calcium source
o Calcium supplementation in the form of generic brand calcium and Oscal-D:
 elemental Ca (500 mg/tablet) with vitamin D (200 IU/tablet): we usually
recommend 1 tablet po bid, but check to make sure they are getting enough
for their daily requirements.
o Calcium supplementation in the form of TUMS:
 Regular Tums contains 200 mg of elemental calcium in each chewable tablet
(500 mg of calcium carbonate).
 TUMS E-X Extra Strength contains 300 mg of elemental Ca (750 mg of
calcium carbonate)
 TUMS Ultra contains 400 mg of elemental Ca (1000 mg calcium carbonate)
 TUMS 500 contain 500 mg of elemental calcium
o Calcium supplementation in the form of Viactiv chews:
 Contains 500 mg of elemental calcium, 100 IU vitamin D, some Na, some
vitamin K per chew
o Calcium supplementation in the form of calcium citrate (e.g. Caltrate 600 + D):
 Some patients complain of gas, abdominal distention and/or constipation with
calcium carbonate. If this is the case, calcium citrate is recommended.
 Calcium citrate can be taken on an empty stomach or after a meal – it is well
absorbed in either situation.
 Caltrate 600 + D contains 600 mg of elemental calcium with vitamin D 200
IU (tablets and soft chews)
 There’s also a Caltrate 600 PLUS tablet and chewable in different flavors that
has the elemental calcium 600 mg, vitamin D 200 IU, as well as other
minerals like Mg, Zn, Cu, Manganese
 Although this may seem like the biggest bang for the buck, calcium
absorption is optimal when taken in amounts of 500 mg or less.
o MVI (example here is for Centrum MVI): 1 tablet contains vitamin D 400 IU and
calcium 162 mg.
o Be careful! Look at tablets overall Calcium dose and the elemental Calcium dose. We
are interested in the elemental Ca.

Interesting tidbits:
o 99% of the body’s calcium is stored in the bones and teeth
o most of the calcium stored in bones is built up before the age of 20
o Excellent dietary sources of calcium include milk, cheese, yogurt, calcium fortified
foods, salmon, sardines, tofu, almonds, brazil nuts, cauliflower, soybeans, seaweed/
kelp, and dark green, leafy veggies (broccoli, collard greens, kale).
o There are some studies that suggest that the benefits of calcium from the diet are
longer lasting than from supplements in the form of pills. However, if you cannot
meet the daily needs from diet alone, supplements are recommended.
o Calcium can interfere with the absorption of iron, so it's best to take the two minerals
at different times of the day if the patient is also on an iron supplement.
Vitamin D: (vitamin D-25-OH)
 Long-acting, storage form of vitamin D. Measuring serum vitamin D, 25-OH concentrations
reflects the total body stores of vitamin D (as opposed to the concentrations of vitamin D,
1,25-OH that change rapidly in response to calcium levels).
 Daily intake of 400 I.U. should maintain normal stores in individuals with normal absorption.
However, some patients need more and the serum vitamin D, 25-OH concentration is the best
way to check if more vitamin D is needed.
 If vitamin D-25-OH level  20, start treatment:
o Vitamin D-25-OH 50,000 IU po q week x 6 doses for children > age 5; 10,000 IU q
week for 6 weeks if < age 5.
o Repeat level after treatment; goal is >20
o Vitamin D has also been delivered as a one time injection of 100,000 IU IM, but this
regimen has had some failures in efficacy and may not be available at present.
 Vitamin D sources: Fish liver oils, seafood, fortified dairy products
“Dietary Reference Intakes (DRIs): Recommended Intakes for Individuals” from the Food and Nutrition
Board, Institute of Medicine, National Academies: www.nap.edu. Calcium and vitamin D are listed as
adequate intake values, not RDA. Fe and Mg are RDA values.
** According to this source and the AAP, the recommendation for vitamin D is 200 IU/day, but many
experts say ≥ 400 IU/ day (including Laura Bachrach). **
Life stage
Children
1-3y
4-8y
vitamin D (tolerable upper intake)
Elemental Calcium (tolerable upper intake)
200 IU/day (2000 IU/day)
200 IU/day (2000 IU/day)
500 mg/d (2.5 g/day)
800 mg/d (2.5 g/day)
Males
9-13y
14-18y
19-30y
200 IU/day (2000 IU/day)
200 IU/day (2000 IU/day)
200 IU/day (2000 IU/day)
1300 mg/d (2.5 g/day)
1300 mg/d (2.5 g/day)
1000 mg/d (2.5 g/day)
Females
9-13y
14-18y
19-30y
200 IU/day (2000 IU/day)
200 IU/day (2000 IU/day)
200 IU/day (2000 IU/day)
1300 mg/d (2.5 g/day)
1300 mg/d (2.5 g/day)
1000 mg/d (2.5 g/day)
Pregnancy
14-18y
19-30y
200 IU/day (2000 IU/day)
200 IU/day (2000 IU/day)
1300 mg/d (2.5 g/day)
1000 mg/d (2.5 g/day)
Lactation
14-18y
19-30y
200 IU/day (2000 IU/day)
200 IU/day (2000 IU/day)
DRIs for Iron and Magnesium:
Life stage
Iron (tolerable upper intake)
Children
1-3y
7 mg/d (40 mg/d)
4-8y
10 mg/d (40 mg/d)
1300 mg/d (2.5 g/day)
1000 mg/d (2.5 g/day)
Mg (tolerable upper intake)
80 mg/d (65 mg/d)
130 mg/d (110 mg/d)
Males
9-13y
14-18y
19-30y
8 mg/d (40 mg/d)
11 mg/d (45 mg/d)
8 mg/d (45 mg/d)
240 mg/d (350 mg/d)
410 mg/d (350 mg/d)
400 mg/d (350 mg/d)
Females
9-13y
14-18y
19-30y
8 mg/d (40 mg/d)
15 mg/d (45 mg/d)
18 mg/d (45 mg/d)
240 mg/d (350 mg/d)
360 mg/d (350 mg/d)
310 mg/d (350 mg/d)
Pregnancy
14-18y
19-30y
27 mg/d (45 mg/d)
27 mg/d (45 mg/d)
400 mg/d (350 mg/d)
350 mg/d (350 mg/d)
Lactation
14-18y
19-30y
10 mg/d (45 mg/d)
9 mg/d (45 mg/d)
360 mg/d (350 mg/d)
310 mg/d (350 mg/d)
Infliximab (Remicade) Orders :
• Need documented negative ppd test prior to initiation. Check ppd qyear or after risky
behavior. Check LFTs prior to initiation: if abnormal, check hepatitis b and c serologies
(already standard of care for adults). Nice to know baseline ANA and dsDNA because of the
risk of conversion.
• Vitals prior to start of infusion, at each rate increase, at 1 hour, and at end of infusion.
• Infuse Infliximab 5-10 mg/kg IV through 1.2 micron low-protein-binding filter in 100 cc NS
to run at 25 cc/h for 15 minutes, then if no reaction, increase rate to 50 cc/h until infusion is
completed.
• Because infliximab is a chimeric protein (made with a little bit of mouse), the main problem
are infusion reactions- fever, dyspnea, hypotension, sweating, hives….if that happens, can
slow down the infusion and watch carefully.
• Premedication:
o acetaminophen 10-15 mg/kg/dose, max 650 mg PO x1
o diphenhydramine 1 mg/kg, max dose 50 mg IV or PO x 1
o Hydrocortisone 4 mg/kg, max dose 200 mg IV x 1 OR Solumedrol
• Reaction Meds:
o Epinephrine 0.01 mg/kg of the 1mg/mL solution, max dose 0.3 mg SQ x1
o diphenhydramine 1 mg/kg, max dose 50 mg IV x 1
o Hydrocortisone 2 mg/kg, max dose 100 mg IV x 1
IVIG Orders:
• There are several brands at LPCH: Gammagard S/D, Gamunex, Polygam S/D, CytoGam,
RespiGam, Gamimune N
• Can give maintenance dosing 400 mg/kg IV x 1
• Or, can give treatment doses: 1-2 g/kg IV x 1
• Infusion rate per IVIG policy (in the appendix of Housestaff Manual)
• Use low IgA product IVIG in patients with IgA deficiencies (otherwise, there might be a
reaction)
• Complications are usually infusion related…slow down the rate, give premeds, give reaction
meds. If there is an infusion reaction with one form of IVIG, can switch to another form
which the patient may tolerate better. Other symptoms are of headache (from aseptic
meningitis, usually 1 day after infusion). Watch for hypersensitivity reactions: nausea,
vomiting, fever, chills, wheezing, dyspnea, flushing, hypotension.
• Vitals prior to start of infusion, at each rate increase, at 1 hour, and at end of infusion.
• Premedication:
o acetaminophen 10-15 mg/kg/dose, max 1000 PO 30 minutes before infusion and
q6 hours prn or around the clock
o diphenhydramine 1 mg/kg, max dose 50 mg IV or PO 30 minutes before infusion
and q6hours (can give prn or around the clock)
• Reaction Meds:
o Epinephrine 0.01 mg/kg of the 1mg/mL solution, max dose 0.3 mg SQ x1
o diphenhydramine 1 mg/kg, max dose 50 mg IV x 1
o Hydrocortisone 2 mg/kg, max dose 200 mg IV x 1
o Normal Saline bolus
Pulse Methylprednisolone Orders
• No premeds or reaction meds in this case, but the infusion can cause bradycardia and a
metallic taste in patient’s mouth (leading to nausea). Watch for increased BPs and blood
sugars (may have glucosuria and polyuria).
• Therefore, we often give Solumedrol with some zofran or CaCarbonate.
• Vitals before infusion and q30 minutes x 3 immediately after Solumedrol dose.
• Methylprednisolone 30 mg/kg IV x 1, up to max 1000 mg.
Rituximab Orders
• Because rituximab is a chimeric protein (made with a little bit of mouse), the main problem
are infusion reactions- fever, dyspnea, hypotension, sweating, hives….if that happens, can
slow down the infusion and watch carefully.
• Because of the risk of an infusion reaction, patients are told to hold their antihypertensives
for the day of the infusion, in case they become hypotensive.
• Vitals every 15 minutes for the first hour, then every 30 minutes for the second hour and
every 60 minutes for the remainder of infusion.
•
•
•
•
•
•
Rituximab 375 mg/m2- 500 mg/m2 IV q1-4 weeks for 2 to 4 doses.
First Infusion of rituximab: rituximab solution should be given IV at an initial rate of 0.5
mg/kg/hour to a maximum of 50 mg/hr. If hypersensitivity or infusion related events do not
occur, escalate the infusion rate in 0.5 mg/kg/h to a max of 50 mg/h increments every 30
minutes to a max of 400 mg/h. If infusion related event develops, the infusion should be
temporarily slowed or interrupted. The infusion can continue at one-half the previous rate
upon improvement of the patient symptoms.
Subsequent infusions: administer at an initial rate 1 mg/kg/hr to max of 100 mg/hr, and
increase by 1 mg/kg/h with a max of 100 mg/hr increments at 30 minute intervals to a max of
400 mg/hr as tolerated.
Premedication:
o acetaminophen 10 mg/kg/dose, max 650 PO 30 minutes before infusion and q6
hours prn or around the clock
o diphenhydramine 1 mg/kg, max dose 50 mg IV or PO 30 minutes before infusion
and q6hours (can give prn or around the clock)
Reaction Meds:
o Epinephrine 0.01 mg/kg of the 1mg/mL solution, max dose 0.3 mg SQ x1
o diphenhydramine 1 mg/kg, max dose 50 mg IV x 1
o Hydrocortisone 2 mg/kg, max dose 100 mg IV x 1
Often given with Solumedrol 30 mg/kg/dose with max 1 g IV
Relative Potencies and Equivalent Doses of Corticosteroids
(Glucocorticoid potency compared to hydrocortisone mg for mg basis. Taken from Housestaff
Manual)
Glucocorticoid
Approx Equivalent Dose (mg)
Hydrocortisone
20 mg
Methylprednisolone
4 mg
Prednisone
5 mg
Prednisolone
5 mg
Relative Anti-inflammatory Potency
1
5
4
4
Hydrocortisone is the weakest glucocorticoid. If we use it as the comparator, then
methylprednisolone is 5 x stronger than hydrocortisone, and therefore 4 mg of
methylprednisolone is equivalent to 20 mg of hydrocortisone.