Section 8. Rheumatology

Abbreviations

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DMARD

Disease-modifying antirheumatic drug

HCQ

Hydroxychloroquine

LEF

Leflunomide

MTX

Methotrexate

NSAID

Nonsteroidal anti-inflammatory drug

TNF

Tumor necrosis factor

Table 8.1.1 Pharmacotherapy for Early Rheumatoid Arthritis

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Table 8.1.1 Pharmacotherapy for Early Rheumatoid Arthritis

Treatment by Disease Activityb

Prognostic Features

Low Disease Activity

Moderate Disease Activity

High Disease Activity

No poor prognostic featuresa

DMARD monotherapy

DMARD monotherapy or HCQ PLUS MTX

With poor prognostic featuresa

Combination DMARD therapy: (MTX + HCQ or LEF or sulfasalazine) or (sulfasalazine + HCQ) or (MTX + HCQ + sulfasalazine)

Anti-TNF +/− MTX or combination DMARD therapy: (MTX + HCQ or LEF or sulfasalazine) or (sulfasalazine + HCQ) or (MTX + HCQ + sulfasalazine)

Source: Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology Recommendations for use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arth Care Res. 2012;64(5):625–639.

aPoor prognostic features: Functional limitation, extraarticular disease, bony erosions on radiograph, positive rheumatoid factor, or anticyclic citrullinated peptide antibodies.

bCategorized based on validated scales such as Patient Activity Scale (PAS), Clinical Disease Activity Index, or Disease Activity Score.

Table 8.1.2 Dosing, Adverse Effects, and Monitoring of DMARDs

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Table 8.1.2 Dosing, Adverse Effects, and Monitoring of DMARDs

Agent

Dosing

Adverse Effects

Monitoring

Nonbiologic DMARDS

HCQ

Initial: 400–600 mg PO QD for 4–12 weeks; max 200–400 mg PO QD

Common: GI side effects, photosensitivity, hair bleaching
Serious: Retinopathy (1% after 5–7 years of use), angioedema, hepatotoxicity, bronchospasm, exfoliative dermatitis, Stevens–Johnson syndrome, bone marrow toxicity

Eye exam at baseline and every 5 years or sooner (some experts recommend annual exams); do not exceed the retinopathy threshold 200–400 mg QD; cumulative dose of 1,000 g is associated with retinopathy
CBC with platelet counts during prolonged therapy

MTX

10–15 mg PO once weekly, increase by 5 mg/week every 2–3 weeks to a maximum of 20–30 mg/week

Common: Alopecia (0.5–3%), diarrhea (1–3%), nausea and vomiting (>10%), leukopenia (1–3%), thrombocytopenia (3–10%), dizziness (1–35)
Serious: Hepatic fibrosis (7%), pancytopenia (1–3%), toxic epidermal necrolysis, GI hemorrhage, stomatitis (2–10%), acquired infections

Pregnancy category X
Hepatic function baseline and 1–2 months intervals; renal function (80–90% unchanged in urine)
Chest x-ray prior to initiation, pulmonary function testing prior to initiation

LEF (Arava)

Loading dose: 100 mg PO QD × 3 days
Maintenance: 20 mg PO QD, reduce to 10 mg QD if not tolerated

Common: Alopecia (9–17%), rash (10–12%), diarrhea (17–27%), mouth ulcer (3–5%), headache (7–13%)
Serious: Stevens–Johnson syndrome, toxic epidermal necrolysis, bone marrow toxicity, hepatic necrosis (increased LFTs 1.5–4.4%), opportunistic infections, interstitial lung disease

Pregnancy category X
CBC with platelet counts and LFTS at baseline, ...

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Section 8. Rheumatology

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