In a young female with lupus cerebritis with seizures would you start induction therapy with Rituximab over cyclophosphamide?

I am not aware of a direct comparison of the efficacy of cyclophosphamide versus rituximab for treating lupus cerebritis with seizures. In cases of life-threatening progressive disease, giving both agents has been reported. Choosing between the two should involve in-depth patient education and involvement. The 2025 ACR lupus guidelines recommend use of high-dose corticosteroids (usually IV solumedrol given for 3-5 days at whatever dose the clinician is familiar. Prednisone is initiated after the pulse with addition of a steroid-sparing agent for more rapid taper. Cyclophosphamide is listed as the recommended added immunosuppressant for moderate to severe cases. Mycophenolate is used in some cases of less severe disease. Rituxan is usually u...

The mainstay of treatment for lupus cerebritis or severe inflammatory neuropsychiatric SLE (such as seizures, cerebral vasculitis, psychosis, or encephalopathy attributed to lupus, myelitis) harbors on pulse-dose glucocorticoids followed by a prednisone taper, as well as cyclophosphamide. Cyclophosphamide would be preferred over Rituximab in these patients. If there is concern for the impact of CYC on fertility in a young female patient, one can utilize strategies such as use of a GnRH agonist (e.g., leuprolide) before the CYC administration. For men of reproductive age, sperm cryopreservation with assistance of Urology can also be done before CYC administration.

No, I would choose National Institutes of Health (NIH) Cytoxan, as I've had to switch patients over from rituximab to Cytoxan for this indication. In my experience, I've had more success with Cytoxan as monotherapy, but I often also have to add more therapies, such as intravenous immunoglobulin (IVIG) and plasma exchange (PLEX), because they are still seizing or encephalopathic even after pulse-dose steroids and induction Cytoxan. It is very common for me to see no signs of improvement for an entire week before they start showing signs of improvement. We often end up throwing the kitchen sink, especially when seizure is hard to break.

In the meantime, I always send the autoimmune encephalitis panel if not already sent, because they often co...