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Disease-modifying anti-rheumatic drugs (DMARDs)
| Drug | Dose | Side-effects | Monitoring to detect side-effects |
| Sulfasalazine (enteric coated) | 500 mg daily after food, increasing to 2-3 g daily | Nausea Skin rashes and mouth ulcers |
|
| Neutropenia and/or thrombocytopenia | Initial, 2 weeks, then 4-monthly | ||
| Abnormal liver biochemistry | Initial, 2 weeks, then 4-monthly | ||
| Methotrexate | 2.5 mg increasing to 25 mg weekly, orally or s.c. | Nausea, mouth ulcers and diarrhoea | |
| Abnormal liver biochemistry | Initial, 2 weeks, then monthly | ||
| Neutropenia and/or thrombocytopenia | Initial, weekly, then monthly | ||
| Renal impairment | Initial, then every 3-6 months | ||
| Pulmonary fibrosis (rare) | Baseline chest X-ray | ||
| Leflunomide | 100 mg daily for 1-3 days, then 20 (or 10) mg daily or 10-20 mg daily | Diarrhoea | |
| Neutropenia and/or thrombocytopenia | Initial, then 2 weekly; monthly at 6 months | ||
| Abnormal liver biochemistry | Initial, then 2 weekly; monthly at 6 months | ||
| Alopecia | |||
| Hypertension | |||
| TNF-α blockers | For all | ||
| Etanercept (alone or with methotrexate) | s.c. 25 mg × 2 weekly or 50 mg weekly | Injection site reactions Infections, e.g. TB and septicaemia |
See British Society for Rheumatology Guidelines |
| Adalimumab (with methotrexate) | s.c. 40 mg alternate weeks | Hypersensitivity reactions Heart failure |
www.rheumatology.org.uk/ guidelines/clinicalguidelines |
| Rare – demyelination and autoimmune syndromes | Stop if no response after6 months | ||
| Infliximab (with methotrexate) | i.v. 3-10 mg/kg every 4-8 weeks | Reversible lupus-like syndrome | |
| Other biological agents (used with methotrexate) | |||
| Anakinra | 1 mg/kg s.c. daily | Injection site reaction Serious reactions – rare |
Used after failure of anti-TNF agents |
| Rituximab | i.v. 500-1000 mg | Hypo/hypertension, skin rash, nausea, pruritis, back pain Rare – toxic epidermal necrolysis |
|
| Abatacept | i.v. 10 mg/kg on days 1, 15, 30 and then monthly | Nausea, vomiting Headache Hypersensitivity – rare |
|
| Tocilizumab | i.v. 8 mg/kg infusion | Headache, skin eruption, stomatitis, fever, anaphylactic reactions | Phase III studies |
