Immunosuppressive agents have traditionally been used when glucocorticoids are ineffective. However, immunosuppressive agents have recently been used as a first line treatment. Today, immunosuppressive agents are classified as systemic conventional immunosuppressive agents, biologic agents and molecularly targeted agents. Systemic immunosuppressive agents include cyclophosphamide, cyclosporine, tacrolimus, mycophenolate mofetil (MMF) and methotrexate (MTX). Biologic agents include TNF inhibitors, IL-6 inhibitors, CTLA-4-Ig and CD20 inhibitors. Molecularly targeted agents include JAK inhibitors (tofacitinib). Initially, cyclophosphamide and MMF are used, followed by tacrolimus and mizoribine, in the treatment of systemic lupus erythematosus. MTX is used first in the treatment of rheumatoid arthritis (RA). TNF inhibitors, IL-6 inhibitors and CTLA-4-Ig are also often used to treat RA. However, tofacitinib is not often used, due to the potential for adverse effects. Tacrolimus and intravenous cyclophosphamide are effective in treating dermatomyositis and polymyositis complicated with interstitial pneumonia. While additional immunosuppressive agents are used to treat other collagen diseases, the evidence in support of these remain equivocal.
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