including connective tissue diseases such as systemic sclerosis, systemic lupus

We will discuss some of the common conventional DMARDs

Methotrexate — should be taken with folic acid or Leucovorin

Live vaccines cannot be given to anyone already taking methotrexate.
They should also limit alcohol use because of the increased risk of liver injury with this
combination.
Women should not become pregnant while taking methotrexate.

Hydroxychloroquine It works by inhibiting

Leflunomide It basically works by blocking

How long to DMARDs take to work Conventional DMARDs usually take longer

CHOOSING BETWEEN DMARDs

other medical conditions, of the patient

personal preference. (cost of DMARD, how often it’s taken, administration etc).

How are DMARDs prescribed?

If there is mild to moderate disease the physician may start with a traditional DMARD.
If the symptoms don’t improve enough after a few months, he may increase the dosage or
switch to a different DMARD or add one or more DMARDs including a biologic DMARD to
the treatment plan.
In some cases, one DMARD is used. In others, combinations may be recommended. So the
patient tries different medicines or combinations to find one that works best and has the
fewest side effects.

Monitoring

 All recommended vaccines should be taken before starting DMARDs and influenza
vaccine to be taken each year.

 The risk of herpes zoster (or shingles)

 Since many of these DMARDs require dose adjustment in renal insufficiency,

 For all the biologic DMARDS

DMARDs in Diabetes mellitus

 The most likely connection between type 2 diabetes and Rheumatoid arthritis (RA)
involves
 If you have one you are likely to have another autoimmune disorder
Methotrexate

Severe bone marrow suppression and aplastic anemia have been reported with
concomitant administration of methotrexate (usually in high dosage) along with
some NSAIDs.

Juvenile idiopathic arthritis  Oral, SUBQ: Initial: 0.5 mg/kg once weekly;

maximum initial dose: 15 mg/dose;

if symptoms worsen or are unchanged after 4 weeks, may increase to SUBQ: 1

mg/kg; maximum dose: 25 mg/dose

10-15 mg/m2 per week, up to a maximum of 25 mg per week.

Low dose methotrexate therapy of RA and psoriasis with dose of 7.5–25 mg/week
versus high dose methotrexate therapy of 1–5 g/week in cancer.

Increases the adenosine concentration at the site of inflammation.

Folic acid reduces the risk of hepatotoxicity and gastrointestinal side effects.

Sulfasalazine

Juvenile idiopathic arthritis: 6 -16 years: Oral: 30 to 50 mg/kg/day in 2 divided

doses; maximum daily dose: 2,000 mg/day

Hydroxychloroquine

Juvenile dermatomyositis: Children and Adolescents: Maximum of 5

mg/kg/day to mitigate risk of retinal toxicity in 1 to 2 divided doses. maximum
daily dose: 400 mg/day.

Leflunomide 10-20 mg once daily

Certolizumab Pediatric: Malignancies have been reported among children and

adolescents receiving TNF-blocking agents.

Cyclophosphamide urinary tract and bladder cancer

Biologics in pediatrics: Etanercept, Adalimumab, Infliximab, Anakinra, tocilizumab,

Abatacept, rituximab
Not used in pediatrics: Certolizumab, apremilast, baricitinib (only tofacitinib used)

Adalimumab 10-40 mg every other week in JIA

Anakinra JIA: Children and Adolescents: SubQ: Initial: 1 to 2 mg/kg/dose once

daily; maximum initial dose: 100 mg;

if no response, may titrate typically at 2-week intervals by doubling dose up to 4

mg/kg/dose once daily; maximum dose: 200 mg

Rheumatoid arthritis: Adolescents ≥18 years: SubQ: 100 mg once daily

In hospitalized patients

Tocilizumab

(Given with systemic corticosteroids like dexamethasone)

Children ≥2 years and Adolescents:

<30 kg: IV: 12 mg/kg/dose once.

≥30 kg: IV: 8 mg/kg/dose once; maximum: 800 mg/dose.

Baricitinib

Children 2 to <9 years: Oral: 2 mg once daily for 14 days or until hospital
discharge

Children ≥9 years and Adolescents: Oral: 4 mg once daily for 14 days or until
hospital discharge