Some consider at least Imuran and Methotrexate to have less risk to them
than pred.  Some can't tolerate prednisone's side effects.  But I think in
general, yes, they are used in cases that need big guns but aren't
responding to pred.  Cytoxan is one of the few (if not the only) drug that
directly crosses the blood-brain barrier to suppress immune cell activity in
the brain and therefore is the drug of choice for central nervous system
lupus.

Hmm, it's more when you've already failed a bunch of the intermediate drugs.
At least in the US, you have Plaquenil, methotrexate, Azulfidine, and Arava
to try, then a bunch of the newer biotech drugs (though the insurance
companies often kick and scream about the cost if you don't have a concurrant
diagnosis of something like rheumatoid arthritis or chron's disease).  Those
drugs include Enbrel, Remicade (has to be given with MTX), Humira, and
Kineret (though I'm not sure anyone's tried that for lupus).  The biologics
also carry a small risk of causing lupus-like symptoms, so some RDs aren't
willing to use them for patients who just have lupus.  A bunch of us with
with mixed syndromes use these drugs and haven't had problems (other than
the drugs fading out over time), so the risk may be over-stated.  If you
have a bunch of organ involvement, you can't afford, can't obtain, or can't
tolerate the newer biologics, then you move on to the "chemo" drugs.

There's also treatment with immunoglobulins in severe cases, but I'm not
exactly where that fits in.  We had at least one memeber here who's been
through that, and it didn't sound like fun.  

I have mixed lupus and rheumatoid arthritis (the running joke is that a
big ugly troll named "Rhupus" has been kicking my a.s), and I've so far failed
Plaquenil, Azulfidine, Arava, and MTX.  And the Enbrel appears to be fading
out.  Since I can't take MTX, Remicade isn't an option, so we'll probably be
trying Humira next.  Given how incredibly awful _my_ experiences with MTX
were, I might chose non-treatment over Cytoxan or Sandimmune.  Most people
tolerate MTX just fine, but even the mildest of the chemo drugs made me
incredibly ill.  I'm hoping I don't ever have to find out about the stronger
ones.

And I've now posted way more than I'm supposed to be.  My shoulder is still
messed up and I'm waiting on a new keyboard that's supposed to make things
easier for me.

Hi Bin,

My name is Tori and  I recently had a close encounter with Cytoxan, but instead
was able to take Imuran instead. I'm sure you already know they are both
essentially forms of Chemotherapy, Cytoxan w/IV treaments and Imuran is pill
form. I believe they are used to hit different target areas, but I had to take
treaments because my kidneys were failing and thats the step before dialysis.
Imuran is not as intense as cytoxan, but it does have some of the side effects,
such as nausea and hair lose. My hair is pretty thick and it really thinned
out, but it wasnt bad at all. After about 6 weeks  of treatment, the doctor
gave me a rest from it because my kidney function had improved significantly,
and when i went to my next visit to return back on to treatments, my kidney
function was almost to a normal functioning kidney, so I didn't even have to
get back on it. Well I hope this answers your questions. I'd love to answer
anyore questions you have.