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RH30 Rheumatology
Common Medications
Toronto Notes 2019
Table 35. Disease Modifying Anti-Rheumatic Drugs (DMARDs)
Generic Drug Name
COMMONLY USED
hydroxychloroquine $
sulfasalazine $
methotrexate $
leflunomide $$
Trade Name
Plaquenil®
Salazopyrim® Azulfidine® (US)
Rheumatrex® Folex/Mexate®
Arava®
Dosing
400 mg PO OD initially
200-400 mg PO OD maintenance (6.5 mg/kg ideal body weight per day to a maximum of 400 mg/day)
1000 mg PO bid-tid
7.5-25 mg PO/IM/SC qweekly
10-20 mg PO OD
2.5-3 mg/kg/d divided and given in 2 doses PO
50 mg IM q1wk after gradual introduction
2/5 mg/kg/d PO once daily
1 g/m2/mo IV as per protocol
Dosing
25 mg biweekly or 50 mg weekly SC
3-5 mg/kg IV q8wk
40 mg SC q2wk
50 mg SC q mo
400 mg SC q2wk x3 then 200 mg SC q4wk
Day 1: 10mg (AM), titrate up to 30 mg BID by Day 6
IV infusion
2 IV infusions, 2 wk apart
4-8 mg/kg IV q4wk 5 mg BID
Contraindications
Retinal disease, G6PD deficiency
Sulfa/ASA allergy, kidney disease, G6PD deficiency
Bone marrow suppression, liver disease, significant lung disease, immunodeficiency, pregnancy, EtOH abuse
Liver disease, lung disease
Kidney/liver disease, infection, HTN
IBD, kidney/liver disease
Kidney/liver disease TPMT deficiency
Kidney/liver disease
Mechanism of Action
Fusion protein of TNF receptor
Chimeric mouse/human monoclonal anti-TNF Monoclonal anti-TNF
Monoclonal anti-TNF
PEGylated monoclonal anti-TNF
Inhibitor of PDE4 which inhibits production of TNFα
Costimulation modulator of T-cell activation
Causes B-cell depletion, binds to CD20
Interleukin-6 receptor antagonist
Inhibits the JAK enzyme and thus interferes with JAK-STAT signaling pathway
NOT COMMONLY USED
Adverse Effects
GI symptoms, skin rash, macular damage, neuromyopathy Requires regular ophthalmological screening to monitor for retinopathy
GI symptoms, rash, H/A, leukopenia
Oral ulcers, GI symptoms, cirrhosis, myelosuppression, pneumonitis, tubular necrosis
Alopecia, GI symptoms, liver dysfunction, pulmonary infiltrates
HTN, decreased renal function, hair growth, tremors, bleeding
Rash, mouth soreness/ulcers, proteinuria, marrow suppression
Rash, pancytopenia (especially WBC,AST, ALT), biliary stasis, vomiting, diarrhea
Cardiotoxicity, GI symptoms, hemorrhagic cystitis, nephrotoxicity, bone marrow suppression, sterility
cyclosporine $$
gold (injectable) $
azathioprine $
cyclophosphamide $
Generic Drug Name
Neoral®
Solganal® Myocrysine®
Imuran® Cytoxan®
Trade Name
NEWER DMARDs (Biologics)
etanercept $$$
infliximab $$$
adalimumab $$$
golimumab $$$
certolizumab $$$
apremilast $$$
abatacept $$$
rituximab $$$
tocilizumab $$$
tofacitinib $$
Enbrel® Remicade® Humira® Simponi® Cimzia®
Otezla®
Orencia® Rituxan® Actemra® Xeljanz®
and Fc portion of lgG
Risks of Biologics
Reactivation of TB or hepatitis B. Patients require negative TB skin test, chest x-ray and negative hepatitis B virus serology prior to starting any of these medications Increasedriskof: seriousinfections, worsening heart failure, multiple sclerosis, and positive auto-antibodies