How is thalidomide used in the treatment of rheumatic diseases?
Thalidomide (Thalomid) has antiinflammatory, immunomodulatory, and antiangiogenic properties. Due to its side effects, it is currently rarely used for rheumatic illness. A major effect may be its ability to reduce tumor necrosis factor-α production by 40%. It is not immunosuppressive and has not been associated with opportunistic infections. At doses of 50 to 300 mg/day, it has been useful to treat inflammatory skin diseases associated with Behcet’s disease and SLE that are resistant to standard therapy. It is particularly useful for severe oral and/or genital ulcerations. Major toxicities include sedation, constipation, rash, sensory polyneuropathy, blood clots, and teratogenicity (phocomelia). The FDA requires registration for its use and following stringent regulations and guidelines for use (call 1-888-423-5436 to get application for use). A progressive and irreversible polyneuropathy seen in up to 50% is more common in women and not related to daily or cumulative dose. It is recommended that a baseline electromyography/nerve conduction velocity be performed and repeated every 6 months. A decline in the sensory nerve action potential by 50% or development of subjective complaints requires discontinuation of the drug.
Lenalidomide (Revlimid) is similar to thalidomide but potentially less toxic. Its major toxicity is thrombocytopenia more than neutropenia. It is less likely than thalidomide to cause blood clots and sensory polyneuropathy.