1. Non-Biologic DMARDS (1st line)
1.1. MTX (first line)
1.1.1. Dose: 7.5, 15, 20mg once weekly (max 250) PLUS folic acid 1mg daily
1.1.2. MOA: Inhibits dihydrofolate reductase resulting in interfering with DNA synthesis
1.1.3. CI: Pregnancy (X), liver disease
1.1.4. ADRs: Ulcerative stomatitis, N/V, GI distress, leukopenia, infection risk, pulmonary/liver toxicity
1.1.5. DDIs: Phenytoin, salicylates, sulfonamides, NSAIDS
1.1.6. Monitoring: LFTs, Scr
1.2. Hydroxychloroquine
1.2.1. Dose: 200-400mg per day
1.2.2. ADRs: HA, N/V/D, retinopathy, photosensitivity, rash
1.2.3. Monitoring: LFTs, opthalamic exams (base and annual after 5 years of use)
1.3. Sulfasalazine
1.3.1. ADRs: HA, rash, N/V, dyspepsia
1.3.2. Monitoring: CBC with diff, dermatologic toxicity, G6PD deficiency
1.3.3. DDIs: NSAIDS, MTX (enhances hepatotoxicity)
1.4. Leflunomide (less commonly used)
1.4.1. Dosing: 10, 20mg tablets
1.4.2. ADRs: Alopecia, skin rash, elevated LFTs, interstitial lung disease
1.4.3. Monitoring: signs of severe infection/pulmonary symptoms, teratogenic
2. Biologic DMARDS
2.1. Non-TNFs (3rd line)
2.1.1. Rituximab
2.1.1.1. Dosing: IV
2.1.1.2. ADRs: Peripheral edema, neuropathy, fatigue, blood dyscrasias
2.1.1.3. DDIs: Diminished effect of vaccines
2.1.1.4. Monitoring: Hypersensitivity (angioedema), cardiac monitoring with BP and ECG
2.1.2. Tocilizumab
2.1.2.1. ADRs: Increased serum cholesterol, increased LFTs, HTN, neutropenia
2.1.2.2. DDIs: Macrolide, azoles, warfarin, HIV meds
2.1.2.3. Monitoring: LFTs, bilirubin, lipids
2.1.3. Abatacept
2.1.3.1. ADRs: HA, infection (URI), N
2.1.3.2. Diminished effect of vaccines
2.1.4. Tofacitinib
2.1.4.1. MOA: Inhibits Janus kinase (JAK)
2.1.4.2. ADRs: HTN, anemia
2.1.4.3. DDIs: Cyclosporine, azathioprine, tacrolimus, rifampin, clarithro/erythromycin (increase concentration), azoles (increase concentration)
2.1.4.4. CI: Do not initiate if lymphocytes <500, neutrophils <1000, or hemoglobin <9
2.1.4.5. Monitoring: Hemoglobin, lipids, HR, BP
2.2. TNFs (2nd line)
2.2.1. Mabs
2.2.1.1. Adalimumab
2.2.1.1.1. Dosing: Sub Q weekly or every other week
2.2.1.1.2. ADRs: Skin rash, injection site reaction, increased phosphokinase
2.2.1.1.3. DDIs: Cyclosporine, warfarin + theophylline
2.2.1.2. Infliximab
2.2.1.2.1. Dosing: IV maintenance 3mg/kg Q8 weeks
2.2.1.2.2. ADRs: Increased ALT, infection (URI), infusion related reaction
2.2.1.2.3. DDIs: Immunosuppressant toxicity, diminished effects of vaccines
2.2.1.2.4. Monitoring: HBV/TB screen, worsening CHF, LFTs
2.2.1.3. Golimumab
2.2.1.3.1. Dosing: IV every 8 weeks, Sub Q monthly
2.2.1.3.2. ADRs: Infection, infection (URI)
2.2.1.3.3. DDIs: Diminished effect of vaccines
2.2.2. Non-mabs
2.2.2.1. Entanercept
2.2.2.1.1. Dosing: Sub Q weekly
2.2.2.1.2. ADRs: Infection (URI), injection site reaction
2.2.2.1.3. DDIs: Immunosuppressant toxicity, diminished effects of vaccines
2.2.2.1.4. Monitoring: HBV/TB screen, signs/sx of infection or malignancy
2.2.2.2. Certolizumab
2.2.2.2.1. Dosing: Sub Q
2.2.2.2.2. ADRs: N, infection (URI)
2.2.2.2.3. DDIs: Diminished effect of vaccines