TABLE 351-2 DMARDs Used for the Treatment of Rheumatoid Arthritis

Drug Dosage Serious toxicities Other common side Initial evaluation Monitoring
effect

Hydroxychloroquine 200–400 mg/d orally Irreversible retinal Nausea Diarrhea Eye examination if >40 Optical coherence
(≤5 mg/kg) damage Headache Rash years old or prior tomography and visual
ocular disease field testing every
Cardiotoxicity Blood
dyscrasia 12 months

Sulfasalazine Initial: 500 mg orally Granulocytopenia Nausea Diarrhea CBC, LFTs G6PD level CBC every 2–4 weeks
twice daily Headache for first 3 months, then
Hemolytic anemia (with every 3 months
Maintenance: 1000– G6PD deficiency)
1500 mg twice daily

Methotrexate 10–25 mg/week orally Hepatotoxicity Nausea CBC, LFTs CBC, creatinine, LFTs
or SQ Myelosuppression every 2–3 months
Infection Diarrhea Viral hepatitis panela
Folic acid 1 mg/d to Stomatitis/mouth Chest x-ray
reduce toxicities Interstitial pneumonitis ulcers Alopecia
Pregnancy category X
Fatigue

Leflunomide 10–20 mg/d Hepatotoxicity Alopecia Diarrhea CBC, LFTs CBC, creatinine,
Myelosuppression
Infection Viral hepatitis panela LFTs every 2–3
months
Pregnancy category X

TNF-α Inhibitors Infliximab: 3 mg/kg IV ↑ Risk bacterial, fungal Infusion reaction ↑ PPD skin test LFTs periodically
at weeks 0, 2, 6, then infections LFTs
every 8 weeks. May PPD skin test Monitor for injection
increase dose up to 10 Reactivation of latent TB Injection site site reactions
mg/kg every 4 weeks reaction PPD skin test
↑ Lymphoma risk Monitor for injection
(controversial) Injection site PPD skin test site reactions
reaction
Drug-induced lupus PPD skin test Monitor for injection
Neurologic deficits Injection site site reactions
reaction
As above Monitor for injection
Injection site site reactions
As above reaction

As above

As above

Monitor for infusion

Abatacept Monitor for infusion ↑ Risk bacterial, viral Headache Nausea PPD skin test reaction
reactions infections

Weight based:

<60 kg: 500 mg

60–100 kg: 750 mg

>100 kg: 1000 mg

IV dose at weeks 0, 2,
 and 4, and then every
4 weeks

OR

125 mg SQ weekly

100mg SQ daily
Anakinra ↑ Risk bacterial, viral Injection site PPD skin test CBC every month for
infections reaction Headache
CBC with differential 3 months, then every
Reactivation of latent TB
Neutropenia 4 months for 1 year
Monitor for injection
site reactions

Rituximab 1000 mg IV × 2, days 0 ↑ Risk bacterial, viral Rash CBC

and 14 infections
Fever Viral hepatitis panela
May repeat course Infusion reaction
every 24 weeks or Cytopenia
more
Hepatitis B reactivation
Premedicate with
methyl- prednisolone
100 mg to decrease
infusion reaction

Tocilizumab 4–8 mg/kg Risk of infection Infusion PPD skin test CBC and LFTs at
reaction LFT elevation regular intervals
4–8 mg/kg IV monthly Dyslipidemia Cytopenias

OR

162 mg SQ every
other week (<100 kg
weight)

162 mg SQ every
week (≥100 kg weight)

Tofacitinib 5 mg orally BID OR Risk of infection LFT Upper respiratory PPD skin test CBC, LFTs, and lipids
elevation Dyslipidemia tract infections at regular intervals
11 mg orally daily Neutropenia
Diarrhea Headache
Nasopharyngitis