2- DMARDS

• DMARDS


  Disease-modifying antirheumatic drugs
• Before starting DMARDs, screen for latent TB, Hep B, & Hep C
• Methotrexate


  • Best initial DMARD for RA
  • Dose as needed/tolerated up to 25mg/week
  • If can't take MTX, give leflunomide, sulfasalazine, hydroxychloroquine, TNF alpha inhibitor (etanercept or adalimumab)
  • Need to take daily folic acid supplement
• Methotrexate side effects


  • Liver toxicity (monitor LFTs)
  • Mouth ulcers and diarrhea
  • BM toxicity (antifolate " pancytopenia, monitor CBC)
  • Lung fibrosis (yearly PFT)
• Stop methotrexate 2-3 months before conception as it is teratogenic
• Anti-TNF (TNF alpha inhibitors)


  • EX: Infliximab, adalimumab, etanercept, golimumab, certolizumab
  • Must screen with PPD prior to use (may cause reactivation of TB)
  • 1st line if not responding/intolerant of MTX (active disease despite 2 DMARDs)
  • Often primarily used in combination with MTX
  • Safe in pregnancy
  • Contraindicated in HF. Toxicity: may lead to infections
• Hydroxychloroquine (Plaquenil)


  • Can be used as monotherapy in mild cases, but usually in combination with MTX
  • Safe in pregnancy
  • Side effect: retinal toxicity (dilated eye exam, baseline ophthalmic evaluation before starting, examine fundus within 1st year, begin annual screening after 5 years of use)
• Sulfasalazine


  • Side effects: mouth ulcers, hepatitis, reversible male infertility, rash, BM toxicity, hemolysis with G6PD deficiency
  • Safe in pregnancy
• Leflunomide


  • Blocks T-cell proliferation
  • Side effects: diarrhea, HTN, hepatitis, alopecia
• Rituximab


  • Anti-CD20 B-cells
  • Subcutaneous
• Tocilizumab


  • IL-6 inhibitor
  • Subcutaneous
• Abatacept


  Blocks T-cell activation
• Anakinra


  IL-1 receptor blocker
• JAK inhibitor


  Systemic DMARDS
• Gold salts


  Side effect: nephrotic syndrome