Arthritis Treatments: DMARDs and Other Immune Modulators
| ARTHRITIS TREATMENTS: DMARDS AND OTHER IMMUNE MODULATORS | ||||
|---|---|---|---|---|
| Generic & Class | Brand & Company | Strength(s) | Formulations* | Usual Dose |
| DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) | ||||
| azathioprine | Azasan
Salix |
75mg, 100mg | scored tabs | Adults: Initially 1mg/kg (50mg–100mg) daily in
1–2 divided doses; after 6–8 wks, if needed, may increase by 0.5mg/kg daily
increments every 4 weeks. Max 2.5mg/kg per day. Maintenance: use lowest effective dose.
Children: Not recommended. |
| Imuran
Prometheus Labs |
50mg | scored tabs | ||
| auranofin | Ridaura
Prometheus Labs |
3mg | caps | Adults: Initially 6mg daily in 1–2 divided doses. If
response inadequate after 6 months, may increase to 3mg 3 times daily. If still ineffective
after 3 months, discontinue.
Children: Not recommended. |
| cyclosporine (modified) | Neoral
Novartis |
25mg, 100mg | caps† | Adults: Give consistently with regards to meals,
diluent, and time of day. ≥18yrs: 1.25mg/kg twice daily; may increase by
0.5–0.75mg/kg per day after 8 weeks and again after 12 weeks; max 4mg/kg per day
(Concomitant MTX therapy may be treated with doses of 3mg/kg/day or less). Reduce dose by
25–50% if adverse events (eg, hypertension or SCr increases ≥30% above baseline)
occur. Discontinue if adverse events are severe or persistent, or if no benefit by week 16.
Children: <18yrs: not recommended. |
| Neoral Oral Solution
Novartis |
100mg/mL | soln† | ||
| hydroxychloroquine | Plaquenil
Sanofi-aventis |
200mg | tabs | Adults: RA: Initially 400–600mg daily with food or
milk. Lupus: initially 400mg 1–2 times daily. Maintenance for both:
200–400mg daily.
Children: Not recommended. |
| leflunomide | Arava
Sanofi-aventis |
10mg, 20mg, 100mg | tabs | Adults: ≥18yrs: Loading dose: 100mg daily for three days;
maintenance 20mg daily. If not well tolerated, may reduce to 10mg daily; monitor closely. If
ALT elevations >3×ULN, discontinue and give cholestyramine and activated charcoal as
needed. Max 20mg/day.
Children: <18yrs: not recommended. |
| methotrexate sodium | Rheumatrex
Stada |
2.5mg | scored tabs | Adults: Initially 7.5mg once per week as a single dose, or a
course of three 2.5mg doses at 12-hour intervals once per week; max 20mg/week.
Children: <2yrs: not recommended. ≥2yrs: initially 10mg/m² once weekly; max 20mg/m² per week. |
| sulfasalazine | Azulfidine EN
Pfizer |
500mg | enteric coated tabs | Adults: Swallow whole after meals. Initially 500mg in the PM for
1 week, then 500mg in the AM & PM for 1 week, then 500mg in the AM and 1g in the PM for 1
week, then 1g in the AM & PM in 2 evenly divided doses.
Children: <6yrs: not recommended. ≥6yrs: initially ¼ to ½ of maintenance dose; increase weekly. Maintenance: 30–50mg/kg per day in 2 evenly divided doses; max 2g/day. |
| TUMOR NECROSIS FACTOR (TNF) BLOCKERS | ||||
| adalimumab | Humira
AbbVie |
20mg/0.4mL, 40mg/0.8mL | soln for SC inj | Adults: ≥18yrs: 40mg every other week. RA (without
MTX): may increase frequency to once weekly.
Children: <4yrs or <15kg: not recommended. 4–17yrs: (15kg to <30kg): 20mg every other week (20mg prefilled syringe should be used): (≥30kg): 40mg every other week. |
| certolizumab pegol | Cimzia
UCB |
200mg/mL | soln for SC inj | Adults: 400mg (two 200mg inj) SC on day 1, then at weeks 2
and 4, followed by 200mg every other week. Maintenance: may consider 400mg every 4 weeks.
Children: Not recommended. |
| 200mg/vial | pwd for SC inj after reconstitution | |||
| etanercept | Enbrel
Amgen |
25mg/vial | pwd for SC inj after reconstitution | Adults: 50mg prefilled syringe or SureClick autoinjector SC once
weekly.
Children: <2yrs: not recommended. JIA: 2–17yrs: 0.8mg/kg per week; max 50mg/week. ≥63kg: may use 50mg prefilled syringe or SureClick autoinjector. |
| 50mg/mL | soln for SC inj | |||
| golimumab | Simponi
Janssen |
50mg/0.5mL | soln for SC inj | Adults: 50mg SC once monthly.
Children: <18yrs: not recommended. |
| infliximab | Remicade
Janssen |
100mg/vial | pwd for IV infusion after reconstitution and dilution | Adults: Give by IV infusion over at least 2 hours.
RA: 3mg/kg at weeks 0, 2, 6, then every 8 weeks. May increase to
10mg/kg or give every 4 weeks. Ankylosing spondylitis: 5mg/kg at weeks 0, 2, 6
then every 6 weeks. Psoriatic arthritis: 5mg/kg at weeks 0, 2, 6, then every
8 weeks. All: max 5mg/kg in CHF.
Children: Not recommended. |
| INTERLEUKIN-1 RECEPTOR ANTAGONIST | ||||
| anakinra | Kineret
Sobi |
100mg/0.67mL | soln for SC inj | Adults: ≥18yrs: 100mg SC once daily.
Children: <18yrs: not recommended. |
| INTERLEUKIN-6 RECEPTOR INHIBITOR | ||||
| tocilizumab | Actemra
Genentech |
20mg/mL | soln for IV infusion after dilution | Adults: RA: Give as a 60-minute single IV infusion. Initially 4mg/kg every
4 weeks, followed by an increase to 8mg/kg every 4 weeks based on clinical response. Doses
>800mg per infusion: not recommended. Do not start if ANC<2000/mm³, platelets <100000/mm³, or
ALT/AST >1.5×ULN. Reduce dose to 4mg/kg if elevated liver enzymes, neutropenia, or thrombocytopenia
occur (see literature).
Children: RA: not recommended. SJIA: <2yrs: not recommended. ≥2yrs: Give once every 2 weeks as a 60-minute IV infusion. <30kg: 12mg/kg. ≥30kg: 8mg/kg. Do not start if ANC<2000/mm³, platelets <100000/mm³, or ALT/AST >1.5×ULN. May need to interrupt dose if elevated liver enzymes, neutropenia, or thrombocytopenia occur. |
| JANUS KINASE INHIBITOR | ||||
| tofacitinib | Xeljanz
Pfizer |
5mg | tabs | Adults: 5mg twice daily.
Children: Not established. |
| SELECTIVE COSTIMULATION MODULATOR | ||||
| abatacept | Orencia
Bristol-Myers Squibb |
250mg/vial | pwd for IV infusion after reconstitution and dilution | Adults: IV regimen: give as IV infusion over 30 min at weeks 0, 2, and 4,
then every 4 weeks thereafter. <60kg: 500mg. 60–100kg: 750mg. >100kg: 1g. SC
regimen: following a single IV loading dose, give the first 125mg SC inj within a day, followed by 125mg SC inj
once weekly. Patients who are unable to receive IV infusion, may begin weekly SC inj without an IV loading dose.
Switching from IV to SC regimen: give the first SC dose instead of the next scheduled IV dose.
Children: Give as an IV infusion over 30 minutes at weeks 0, 2, and 4, then every 4 weeks thereafter. <6yrs: not recommended. 6–17yrs: (<75kg): 10mg/kg; (≥75kg): use adult dose; max 1g. |
| 125mg/mL | soln for SC inj | |||
| CD20 ANTIBODY | ||||
| rituximab | Rituxan
Genentech |
10mg/mL | soln for IV infusion | Adults: Give glucocorticoids 30 minutes prior to each infusion.
Concomitant MTX therapy: give two 1000mg IV infusions separated by 2 weeks. Subsequent courses
should be given every 24 weeks or based on response, but not sooner than every 16 weeks.
Children: Not recommended. |
| NOTES | ||||
|
* caps = capsules; tabs = tablets; soln = solution; inj = injection; † = contains alcohol. RA = Rheumatoid arthritis; MTX = methotrexate; JIA = Juvenile rheumatoid arthritis. Not an inclusive list. Some of the products listed above have additional indications. See Alphabetical and Section indexes. (Rev. 4/2013) |
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