Advances in immunosuppressive drug therapy for use in autoimmune disease and systemic vasculitis

Several recent advances in the use of immunosuppressive drugs in autoimmune disease are relevant to management of autoimmune pulmonary disease. Sequential immunosuppression combining remission induction with cyclophosphamide with less toxic maintenance therapy such as azathioprine, methotrexate, or mycophenolate mofetil is described in Wegener's granulomatosis, systemic vasculitis, and lupus. Less aggressive forms of diseases that have been routinely treated with cyclophosphamide have been treated with alternate regimens (e.g., methotrexate treatment of limited Wegener's granulomatosis, and mycophenolate mofetil for lupus). Finally, strategies to minimize severe side effects of immunosuppression include genetic testing for predisposition to drug toxicity and proposed techniques for fertility preservation during cyclophosphamide treatment. We review established principles of immunosuppressive drug use and focus on clinical trials in autoimmune diseases that illustrate therapeutic approaches which are likely to be applied more widely in the future. More detailed reviews of treatment of individual diseases will be found in elsewhere in this issue.