Rheumatoid Arthritis - DMARD Therapy
This calculator provides general pharmacologic treatment guidelines for
rheumatoid arthritis (RA) based on the latest evidence (Oct 2017). Medications
listed will have direct links to the latest package insert. Based on the
selections below, this tool will provide possible treatment strategies that have
been studied. This initial program covers only disease-modifying antirheumatic drugs (DMARDs):
disease-modifying antirheumatic drugs (DMARDs)
- Biologic DMARDs, which include:
- TNF-α inhibitor biologics and
- Non-TNF biologics.
Instructions: review each section and make a selection
based on the information provided.
Methotrexate (Trexall): Rheumatoid arthritis: Dosing: Initially:
Oral: 7.5 mg once weekly
or 2.5 mg q12h for 3 doses/week - adjust dose gradually based on
response. IM: 7.5 mg once weekly - adjust
dose gradually based on the optimal response. Usual
maintenance: Oral or IM: 7.5-15 mg once weekly. [Regardless of
the route of administration, doses above 20mg/week are associated with
increased risk of toxicity.] Consider adding folic acid (~5mg/week) to
reduce possible adverse reactions (hematologic, gastrointestinal, and
hepatic). Folic acid should not be administered on the same day as
methotrexate. Methotrexate may also be given subcutaneously.
Leflunomide (Arava): Rheumatoid arthritis: Dosing:
The recommended dosage of ARAVA is 20 mg once daily. Treatment may be
initiated with or without a loading dose, depending upon the patient's risk
of ARAVA-associated hepatotoxicity and ARAVA-associated myelosuppression.
The loading dosage provides steady-state concentrations more rapidly.
>For patients who are at low risk for ARAVA-associated hepatotoxicity and
ARAVA-associated myelosuppression the recommended ARAVA loading dosage is
100 mg once daily for 3 days. Subsequently administer 20 mg once daily.
>For patients at high risk for ARAVA-associated hepatotoxicity (e.g., those
taking concomitant methotrexate) or ARAVA-associated myelosuppression (e.g.,
patients taking concomitant immunosuppressants), the recommended ARAVA
dosage is 20 mg once daily without a loading dose.
The maximum recommended daily dosage is 20 mg once per day. Consider dosage
reduction to 10 mg once daily for patients who are not able to tolerate 20
mg daily (i.e., for patients who experience any adverse events.
- Rheumatoid arthritis: The action of hydroxychloroquine is cumulative and
may require weeks to months to achieve the maximum therapeutic effect. Dosing:
Initial adult dosage: 400 mg to 600 mg (310 to 465 mg base) daily,
administered as a single daily dose or in two divided doses. In a small
percentage of patients, side effects may require temporary reduction of the
initial dosage. Maintenance adult dosage: When a good response is
obtained, the dosage may be reduced by 50 percent and continued at a
maintenance level of 200 mg to 400 mg (155 to 310 mg base) daily,
administered as a single daily dose or in two divided doses. Do not
exceed 600 mg or 6.5 mg/kg (5 mg/kg base) per day, whichever is lower, as
the incidence of retinopathy has been reported to be higher when this
maintenance dose is exceeded. Corticosteroids and salicylates
may be used in conjunction with PLAQUENIL, and they can generally be
decreased gradually in dosage or eliminated after a maintenance dose of
PLAQUENIL has been achieved.
Sulfasalazine (Azulfidine): Rheumatoid
arthritis: Dosing: Initially: Oral: 500mg once daily or 1
g/day (500mg bid). It is advisable to initiate therapy
with a lower dosage of sulfasalazine delayed release tablets, e.g., 0.5 to 1
g daily, to reduce possible gastrointestinal intolerance. Usual maintenance: Oral:
Increase weekly to 1 gram twice daily (Consideration can be given to
increasing the daily dose of sulfasalazine delayed release tablets to 3 g if
the clinical response after 12 weeks is inadequate.). Not recommended in renal of hepatic
Adalimumab (Humira)- Rheumatoid arthritis: Dosing:
Administered by subcutaneous injection - 40 mg every other week. Some
patients with RA not receiving methotrexate may benefit from increasing the
frequency to 40 mg every week. Methotrexate (MTX), other non-biologic
DMARDS, glucocorticoids, nonsteroidal anti-inflammatory drugs (NSAIDs),
and/or analgesics may be continued during treatment with HUMIRA.
Certolizumab pegol (Cimzia) - Rheumatoid
CIMZIA is administered by subcutaneous injection. 400 mg initially and at
Weeks 2 and 4, followed by 200 mg every other week; for maintenance dosing,
400 mg every 4 weeks can be considered. When a 400 mg dose is needed
(given as two subcutaneous injections of 200 mg), injections should occur at
separate sites in the thigh or abdomen. Before initiation of therapy with
CIMZIA, all patients must be evaluated for both active and inactive (latent)
tuberculosis infection. CIMZIA may be used as monotherapy or concomitantly
with non-biological disease modifying anti-rheumatic drugs (DMARDs).
The use of CIMZIA in combination with biological DMARDs or other tumor
necrosis factor (TNF) blocker therapy is not recommended.
Etanercept (Enbrel):: Rheumatoid arthritis: Dosing: 50 mg
once weekly administered by subcutaneous injection with or without
methotrexate (MTX). Alternatively: 25 mg twice weekly.
Golimumab (Simponi): Rheumatoid arthritis: Dosing: The SIMPONI dose regimen is
50 mg administered by subcutaneous injection once a month. For patients with
rheumatoid arthritis (RA), SIMPONI should be given in combination with
methotrexate. For patients with RA, PsA, or AS, corticosteroids,
non-biologic DMARDs, and/or NSAIDs may be continued during treatment with
Infliximab (Remicade) -
Dosing: Rheumatoid arthritis:
In conjunction with methotrexate, 3 mg/kg at 0, 2 and 6 weeks, then every 8
weeks. Some patients may benefit from increasing the dose up to 10 mg/kg or
treating as often as every 4 weeks. [REMICADE is administered by intravenous
infusion over a period of not less than 2 hours. ]
Tocilizumab (Actrema) - IL-6 Inhibitor. Rheumatoid arthritis: Note:
May be combined with nonbiologic disease-modifying antirheumatic drugs (DMARDs)
but NOT with biologic DMARDs.
Dosing: Initial: 4 mg/kg IV once every 4 weeks.
May be increased to 8 mg/kg once
every 4 weeks based on clinical response (maximum dose: 800 mg).
<100 kg: 162 mg once every other week; increase to 162 mg once every week
based on clinical response.
100 kg: 162 mg once every week.
Tofacitinib (Xeljanz) - JAK Kinase Inhibitor.
Rheumatoid arthritis: XELJANZ/XELJANZ XR may be used as monotherapy or in
combination with methotrexate or other nonbiologic disease-modifying
antirheumatic drugs (DMARDs). Limitations of Use:
Use of XELJANZ/XELJANZ XR in combination with biologic DMARDs or potent
immunosuppressants such as azathioprine and cyclosporine is not recommended.
It is recommended that XELJANZ/XELJANZ XR not be initiated in patients with
an absolute lymphocyte count less than 500 cells/mm3, an absolute neutrophil
count (ANC) less than 1000 cells/mm3 or who have hemoglobin levels less than
Dosing: Recommended dose
of XELJANZ is 5 mg twice daily. Recommended dose of XELJANZ XR is 11 mg once
daily. Recommended dose in patients with moderate and severe renal
impairment and moderate hepatic impairment is XELJANZ 5 mg once daily. Use
of XELJANZ/XELJANZ XR in patients with severe hepatic impairment is not
Selected drug interactions: Potent
inhibitors of Cytochrome P450 3A4 (CYP3A4) (e.g., ketoconazole): Recommended
dose is XELJANZ 5 mg once daily. One or more concomitant medications
that result in both moderate inhibition of CYP3A4 and potent inhibition of
CYP2C19 (e.g., fluconazole): Recommended dose is XELJANZ 5 mg once daily.
Potent CYP inducers (e.g., rifampin): May result in loss of or reduced
Abatacept (Orencia) - Costimulation Modulator. Rheumatoid arthritis (RA).
Dose is based on body weight:
<60 kg: 500 mg.
60 to 100 kg: 750 mg.
>100 kg: 1,000 mg. IV infusion: Initially start IV
infusion at the weight-based dose, then repeat the IV infusion (using the
same weight-based dose) at 2 weeks and 4 weeks after the initial infusion,
and then every 4 weeks thereafter.
Subcutaneous (SC): Administer by subcutaneous injection once weekly with
or without an intravenous loading dose. For patients initiating therapy with
an intravenous loading dose, administer a single intravenous infusion (as
per body weight categories above), followed by the first 125 mg subcutaneous
injection given within a day of the intravenous infusion. Package Insert
Rituximab (Rituxan) -Anti CD20 Antibody. Rheumatoid arthritis:
The dose for RA in combination with methotrexate is two-1000 mg intravenous
infusions separated by 2 weeks (one course) every 24 weeks or based on
clinical evaluation, but not sooner than every 16 weeks. Methylprednisolone
100 mg intravenous or equivalent glucocorticoid is recommended 30 minutes
prior to each infusion.
Wahl K, Schuna AA. Rheumatoid Arthritis. In: DiPiro JT, Talbert RL, Yee GC,
Matzke GR, Wells BG, Posey LM, editors. Pharmacotherapy: A pathophysiologic
approach. 9th ed. New York: McGraw-Hill Medical; c2014. Chapter 72.
Saag KG, Teng GG, Patkar NM, Anuntiyo J, et al. American College of
Rheumatology 2008 recommendations for the use of nonbiologic and biologic
disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis
Singh JA, Saag KG, et al.2015 American College of Rheumatology Guideline for
the Treatment of Rheumatoid Arthritis. Arthritis Care & Research DOI
10.1002/acr.22783 VC 2015, American College of Rheumatology. Link: https://www.rheumatology.org/Portals/0/Files/ACR%202015%20RA%20Guideline.pdf