Arthritis Treatments: DMARDS and Other Immune Modulators

Arthritis Treatments: DMARDS and Other Immune Modulators
ARTHRITIS TREATMENTS: DMARDS AND OTHER IMMUNE MODULATORS
Generic Brand Strength Form Dose
CD20 ANTIBODY
rituximab Rituxan 10mg/mL soln for IV infusion Adults: RA: Give glucocorticoids 30mins prior to each infusion. First infusion: initially at a rate of 50mg/hr; may increase by 50mg/hr increments every 30mins. Subsequent infusions: initially at a rate of 100mg/hr; may increase by 100mg/hr increments every 30mins. Both: max 400mg/hr if infusion reactions do not occur. In combination with MTX: two 1000mg separated by 2wks. Subsequent courses should be given every 24wks or based on response, but not sooner than every 16wks.
Children: Not established.
Truxima
Riabni
Ruxience
CHELATING AGENT
penicillamine Cuprimine 250mg caps Adults: RA: Take on an empty stomach at least 1hr before meals or 2hrs after meals, and at least 1hr apart from any other drug, food, or milk. Dosages >500mg/day should be administered in divided doses. Initially 125mg or 250mg as a single daily dose; increase by 125–250mg/day at 1- to 3-month intervals based on response and tolerance. If satisfactory remission achieved, continue at remission dose. If no improvement and no signs of serious toxicity after 2–3mos with doses of 500–750mg/day, may increase by 250mg/day at 2- to 3-month intervals until remission occurs or if toxicity develops. Discontinue if no improvement after 3–4mos with 1000–1500mg/day. Maintenance therapy: individualize; usual range 500–750mg/day; some may need less. Patients in remission for ≥6mos: reduce dose gradually in decrements of 125–250mg/day at approximately 3-month intervals. When surgery is contemplated: consider dose reduction to 250mg/day if effects on collagen and elastin made it advisable; delay restarting therapy until wound healing is complete.
Children: Not established.
Depen 250mg titratable tabs
CONVENTIONAL DMARDs
auranofin Ridaura 3mg caps Adults: Initially 6mg daily in 1−2 divided doses. If response inadequate after 6mos, may increase to 3mg 3 times daily. If still ineffective after 3mos, discontinue.
Children: Not recommended.
azathioprine Azasan 75mg, 100mg scored tabs Adults: Initially 1mg/kg/day in 1–2 divided doses. After 6–8wks, if needed, increase by 0.5mg/kg/day increments every 4wks; max 2.5mg/kg/day. Maintenance: use lowest effective dose; can decrease by 0.5mg/kg/day (approx. 25mg daily) every 4wks.
Children: Not established.
Imuran 50mg scored tabs
cyclosporine Gengraf† 25mg, 100mg caps* Adults: ≥18yrs: Give consistently with regard to meals and time of day. 1.25mg/kg twice daily; may increase by 0.5−0.75mg/kg/day after 8wks and again after 12wks; max 4mg/kg/day (many patients on concomitant methotrexate can be treated with doses of 3mg/kg/day or less). Dilute soln in a glass of room temp orange or apple juice. Reduce dose by 25−50% if adverse events (eg, hypertension or serum creatinine increases ≥30% above baseline) occur. Renal impairment: not recommended. Severe hepatic impairment: consider reducing dose.
Children: <18yrs: not established.
Neoral† 25mg, 100mg caps* Adults: ≥18yrs: Give consistently with regard to meals and time of day. 1.25mg/kg twice daily; may increase by 0.5−0.75mg/kg/day after 8wks and again after 12wks; max 4mg/kg/day Concomitant MTX: may treat with 3mg/kg/day or less. Reduce dose by 25−50% if adverse events (eg, hypertension or SCr increases ≥30% above baseline) occur.
Children: <18yrs: not established.
100mg/mL soln*
hydroxy– chloroquine Plaquenil 200mg tabs Adults: RA: Initially 400–600mg daily in 1–2 divided doses with food or milk. Maintenance: 200–400mg daily.
Children: Not established.
leflunomide Arava 10mg, 20mg, 100mg tabs Adults: Arava-associated hepatotoxicity and myelosuppression (low-risk): give 100mg loading dose once daily for 3 days; then 20mg daily thereafter; (high-risk): give 20mg once daily without loading dose. Max 20mg/day. If not well tolerated, may reduce to 10mg daily.
Children: Not established.
methotrexate — 2.5mg scored tabs Adults: RA: Initially 7.5mg once weekly as a single dose, or a course of three 2.5mg doses at 12‑hr intervals once weekly; max 20mg/wk.
Children: <2yrs: not established. PJIA: ≥2yrs: Initially 10mg/m² once weekly; max 20mg/m²/wk.
Otrexup 10mg/0.4mL, 15mg/0.6mL, 17.5mg/0.7mL, 20mg/0.8mL, 22.5mg/0.9mL, 25mg/mL soln for SC inj Adults: RA:Initially 7.5mg SC once weekly; adjust gradually. Use alternative MTX form in patients requiring oral, IM, IV, intra-arterial, or intrathecal dosing, doses <7.5mg/wk or >25mg/wk, high-dose regimens, or dose adjustments <2.5mg increments.
Children: <2yrs: not established. PJIA: ≥2yrs: Initially 10mg/m² SC once weekly; adjust gradually. Use alternative MTX form in patients requiring oral, IM, IV, intra-arterial, or intrathecal dosing, doses <7.5mg/wk or >25mg/wk, high-dose regimens, or dose adjustments <2.5mg increments.
Rasuvo 7.5mg/0.15mL, 10mg/0.20mL, 12.5mg/0.25mL, 15mg/0.30mL, 17.5mg/0.35mL, 20mg/0.40mL, 22.5mg/0.45mL, 25mg/0.50mL, 30mg/0.60mL soln for SC inj Adults: RA: Initially 7.5mg once weekly using oral or SC form. Use alternative MTX form in patients requiring oral, IM, IV, intra-arterial, or intrathecal dosing, doses <7.5mg/wk or >25mg/wk, high-dose regimens, or dose adjustments <2.5mg increments.
Children: <2yrs: not established. PJIA: 2–16yrs:  Initially 10mg/m² once weekly. Use alternative MTX form in patients requiring oral, IM, IV, intra-arterial, or intrathecal dosing, doses <7.5mg/wk or >25mg/wk, high-dose regimens, or dose adjustments <2.5mg increments.
Reditrex 15mg/0.6mL, 20mg/0.8mL, 25mg/mL soln for SC inj Adults: RA: Initially 7.5mg SC once weekly; adjust dose gradually. Use alternative MTX form in patients requiring oral, IM, IV, intra-arterial, or intrathecal dosing, doses <7.5mg/wk or >25mg/wk, high-dose regimens, or dose adjustments <2.5mg increments.
Children: <2yrs: not established. PJIA: ≥2yrs: Initially 10mg/m² SC once weekly; adjust dose gradually. Use alternative MTX form in patients requiring oral, IM, IV, intra-arterial, or intrathecal dosing, doses <7.5mg/wk or >25mg/wk, high-dose regimens, or dose adjustments <2.5mg increments.
Xatmep 2.5mg/mL oral soln Adults: Use other forms.
Children: PJIA: Initially 10mg/m² once weekly; adjust gradually; usual max: 20mg/m² per week.
sulfasalazine Azulfidine  EN 500mg enteric coated tabs Adults: Take after meals. Initially 500mg in the PM for 1wk, then 500mg in the AM & PM for 1wk, then 500mg in the AM and 1g in the PM for 1wk, then 1g in the AM & PM in 2 evenly divided doses.
Children: <6yrs: not recommended. ≥6yrs: Initially ¼ to ⅓ of maintenance dose; increase weekly. Maintenance: 30−50mg/kg/day in 2 evenly divided doses; max 2g/day.
INTERLEUKIN-1 ANTAGONIST
anakinra Kineret 100mg/0.67mL soln for SC inj Adults: ≥18yrs: RA: 100mg SC once daily. Severe renal impairment or ESRD (CrCl <30mL/min): may consider every other day dosing.
Children: <18yrs: not recommended.
canakinumab Ilaris 150mg/vial soln for SC inj Adults and Children: <2yrs: not established. Still’s disease, SJIA: ≥2yrs (≥7.5kg): 4mg/kg (max 300mg) SC every 4wks.
INTERLEUKIN-6 ANTAGONIST
sarilumab Kevzara 150mg/1.14mL, 200mg/1.14mL soln for SC inj Adults: RA: 200mg SC once every 2wks, as monotherapy or in combination with methotrexate or other conventional DMARDs.
Children: Not established.
tocilizumab Actemra 20mg/mL soln for IV infusion after dilution Adults: RA: IV regimen: Infuse over 60mins. Initially 4mg/kg every 4wks, then 8mg/kg every 4wks based on clinical response. Doses >800mg/infusion: not recommended. SC regimen: <100kg: 162mg SC inj every other week, then give once weekly based on clinical response. ≥100kg: 162mg SC inj once weekly. Transitioning from IV to SC admin: give 1st SC dose instead of next scheduled IV dose.
Children: <2yrs: not established. Infuse IV over 60mins. ≥2yrs: SJIA: IV regimen (<30kg): 12mg/kg IV every 2wks; (≥30kg): 8mg/kg IV every 2wks. SC regimen (<30kg): 162mg SC inj every 2wks; (≥30kg): 162mg SC inj once weekly. PJIA: IV regimen (<30kg): 10mg/kg IV every 4wks; (≥30kg): 8mg/kg IV every 4wks. SC regimen (<30kg): 162mg SC inj every 3wks; (≥30kg): 162mg SC inj every 2wks. Transitioning from IV to SC admin: give 1st SC dose instead of next scheduled IV dose.
162mg/ 0.9mL prefilled syringe for SC inj
INTERLEUKIN-12/23 ANTAGONIST
ustekinumab Stelara 45mg/0.5mL, 90mg/1mL soln for SC inj Adults: ≥18yrs: PsA: 45mg SC once then 4wks later, followed by 45mg every 12wks. Co‑existent moderate-to-severe plaque psoriasis weighing >100kg: 90mg once then 4wks later, followed by 90mg every 12wks.
Children: <6yrs: not established. Give by SC at Weeks 0 and 4, then every 12wks thereafter. PsA: 6–17yrs (<60kg): 0.75mg/kg; (≥60kg): 45mg. Co-existent moderate to severe plaque psoriasis weighing >100kg: 90mg.
INTERLEUKIN-17A ANTAGONIST
ixekizumab Taltz 80mg/mL soln for SC inj Adults: ≥18yrs: PsA: 160mg (two 80mg injs) at Week 0, then 80mg every 4wks; may be given alone or in combination with a conventional DMARD. With coexistent plaque psoriasis: 160mg at Week 0, then 80mg at Weeks 2, 4, 6, 8, 10, and 12, then 80mg every 4wks. AS: 160mg at Week 0, then 80mg every 4wks. nr-axSpA: 80mg every 4wks.
Children: <18yrs: not established.
secukinumab Cosentyx 75mg/0.5mL, 150mg/mL, 300mg/2mL soln for SC inj Adults: ≥18yrs: PsA with coexistent plaque psoriasis: 300mg SC at Weeks 0, 1, 2, 3, and 4 then 300mg every 4wks. Other PsA (with a loading dose): 150mg SC at Weeks 0, 1, 2, 3, and 4 and every 4wks thereafter; (without a loading dose): 150mg every 4wks. Consider 300mg every 4wks if PsA continues. May be administered with or without MTX. AS (with a loading dose): 150mg SC at Weeks 0, 1, 2, 3, and 4 and every 4wks thereafter; (without a loading dose): 150mg every 4wks. Consider 300mg every 4wks if AS continues. nr-axSpA (with a loading dose): 150mg SC at Weeks 0, 1, 2, 3, and 4 and every 4wks thereafter; (without a loading dose): 150mg every 4wks.
Children: AS or nraxSpA (<18yrs): not established. PsA (<2yrs or <15kg) or ERA (<4yrs or <15kg): not established. PsA (≥2yrs): ≥15–<50kg: 75mg at Weeks 0, 1, 2, 3, and 4 and every 4wks thereafter; ≥50kg: 150mg at Weeks 0, 1, 2, 3, and 4 and every 4wks thereafter. May be administered with or without MTX. ERA (≥4yrs): ≥15–<50kg: 75mg at Weeks 0, 1, 2, 3, and 4 and every 4wks thereafter; ≥50kg: 150mg at Weeks 0, 1, 2, 3, and 4 and every 4wks thereafter.
INTERLEUKIN-23 ANTAGONIST
guselkumab Tremfya 100mg/mL soln for SC inj Adults: ≥18yrs: PsA: 100mg SC at Weeks 0 and 4, then every 8wks. May be given alone or in combination with a conventional DMARD.
Children: <18yrs: not established.
risankizumab-rzaa Skyrizi 75mg/0.83mL, 150mg/mL soln for SC inj Adults: ≥18yrs: PsA: 150mg SC at Week 0, Week 4, and every 12wks thereafter. May be given alone or in combination with non-biologic DMARDs.
Children: <18yrs: not established.
JANUS KINASE INHIBITOR
baricitinib Olumiant 1mg, 2mg tabs Adults: RA: 2mg once daily
Children: Not established.
tofacitinib Xeljanz 5mg, 10mg tabs Adults: RA, PsA, AS: 5mg twice daily.
Children: <2yrs: not established. PJIA: 2–17yrs (<40kg): use oral soln; (≥40kg): 5mg (tab or oral soln) twice daily.
1mg/mL oral soln Adults: Not applicable.
Children: <2yrs: not established. PJIA: 2–17yrs (10–<20kg): 3.2mg (3.2mL) twice daily; (20–<40kg): 4mg (4mL) twice daily; (≥40kg): 5mg (5mL) twice daily.
Xeljanz XR 11mg ext-rel tabs Adults: RA, PsA, AS: 11mg once daily.
Children: Not established.
upadacitinib Rinvoq 15mg, 30mg, 45mg ext-rel tabs Adults: RA, PsA, AS, nraxSpA: 15mg once daily.
Children: Not established.
PHOSPHODIESTERASE 4 INHIBITOR
apremilast Otezla 10mg, 20mg, 30mg tabs Adults: Active PsA: Day 1: 10mg in AM. Day 2: 10mg in AM and 10mg in PM. Day 3: 10mg in AM and 20mg in PM. Day 4: 20mg in AM and 20mg in PM. Day 5: 20mg in AM and 30mg in PM. Following on Day 6 and thereafter: 30mg twice daily (AM & PM).
Children: <18yrs: not established.
SELECTIVE COSTIMULATION MODULATOR
abatacept Orencia 250mg/vial pwd for IV infusion after reconsti– tution and dilution Adults: IV regimen (RA and PsA): give as IV infusion over 30mins at Weeks 0, 2, and 4, then every 4wks. <60kg: 500mg. 60–100kg: 750mg. >100kg: 1g. SC regimen: For RA (may initiate with or without an IV loading dose): if using an IV loading dose, give a single IV loading dose (based on body wt listed above), followed by the first 125mg SC inj given within a day, then subsequently 125mg SC once weekly. For PsA: 125mg SC inj once weekly without an IV loading dose. Switching from IV to SC regimen: give the first SC dose instead of the next scheduled IV dose.
Children: PJIA: IV regimen: give as IV infusion over 30min at weeks 0, 2, and 4, then every 4wks. <6yrs: not studied. 6–17yrs: (<75kg): 10mg/kg; (≥75kg): use adult dose; max 1g. SC regimen (initiate without an IV loading dose): <2yrs: not established. ≥2yrs: (10–<25kg): 50mg once weekly; (25–<50kg): 87.5mg once weekly; (≥50kg); 125mg once weekly. ClickJect autoinjector: not studied in pediatrics.
50mg/0.4mL, 87.5mg/0.7mL, 125mg/mL prefilled syringe for SC inj
125mg/mL ClickJect autoinjector for SC inj
TUMOR NECROSIS FACTOR (TNF) BLOCKERS
adalimumab Humira 10mg/0.1mL, 10mg/0.2mL, 20mg/0.2mL, 20mg/0.4mL, 40mg/0.4mL, 40mg/0.8mL, 80mg/0.8mL soln for SC inj Adults: RA, PsA, AS: 40mg every other week. May use with MTX, DMARDs, glucocorticoids, NSAIDs, and/or analgesics. RA (without MTX): may increase to 40mg every week or 80mg every other week.
Children: RA, PsA, or AS (<18yrs) or PJIA (<2yrs or <10kg): not established. PJIA: 2–17yrs (10–<15kg): 10mg every other week; (15–<30kg): 20mg every other week; (≥30kg): 40mg every other week. May use with MTX, glucocorticoids, NSAIDs, and/or analgesics.
Abrilada 10mg/0.2mL, 20mg/0.4mL, 40mg/0.8mL
Amjevita 10mg/0.2mL, 20mg/0.2mL, 20mg/0.4mL, 40mg/0.4mL, 40mg/0.8mL, 80mg/0.8mL
Cyltezo 10mg/0.2mL, 20mg/0.4mL, 40mg/0.8mL
Hadlima 40mg/0.4mL (citrate-free), 40mg/0.8mL
Hyrimoz 10mg/0.1mL, 10mg/0.2mL, 20mg/0.2mL, 20mg/0.4mL, 40mg/0.4mL, 40mg/0.8mL, 80mg/0.8mL
Hulio 20mg/0.4mL, 40mg/0.8mL soln for SC inj Adults: RA, PsA, AS: 40mg every other week. May use with MTX, DMARDs, glucocorticoids, NSAIDs, and/or analgesics. RA (without MTX): may increase to 40mg every week or 80mg every other week.
Children: RA, PsA, or AS (<18yrs) or PJIA (<2yrs or <10kg): not established. PJIA: 2–17yrs (15–<30kg): 20mg every other week; (≥30kg): 40mg every other week. May use with MTX, glucocorticoids, NSAIDs, and/or analgesics.
Yuflyma 20mg/0.2mL, 40mg/0.4mL, 80mg/0.8mL (all citrate-free)
Idacio 40mg/0.8mL (citrate-free) soln for SC inj Adults: RA, PsA, AS: 40mg every other week. May use with MTX, DMARDs, glucocorticoids, NSAIDs, and/or analgesics. RA (without MTX): may increase to 40mg every week or 80mg every other week.
Children: RA, PsA, or AS (<18yrs) or PJIA (<2yrs or <10kg): not established. PJIA: 2–17yrs (≥30kg): 40mg every other week. May use with MTX, glucocorticoids, NSAIDs, and/or analgesics.
Yusimry 40mg/0.8mL
certolizumab pegol Cimzia 200mg/mL soln for SC inj Adults: RA, PsA: 400mg (two 200mg inj at separate sites) SC on Day 1, then at Weeks 2 and 4, followed by 200mg every other week. Maintenance: may consider 400mg every 4wks. Ankylosing spondylitis, nr-axSpA: 400mg on Day 1, then at Weeks 2 and 4, followed by 200mg every 2wks or 400mg every 4wks.
Children: Not established.
200mg/vial pwd for SC inj after reconsti– tution
etanercept Enbrel 25mg/vial pwd for SC inj after reconsti– tution Adults: RA, PsA, ankylosing spondylitis: 50mg SC once weekly.
Children: <2yrs: not established. PJIA: ≥2yrs: (<63kg): 0.8mg/kg (max 50mg) weekly; (≥63kg): 50mg weekly.
25mg/0.5mL, 50mg/mL soln for SC inj
golimumab Simponi 50mg/0.5mL, 100mg/mL soln for SC inj Adults: 50mg SC once monthly. RA: give with MTX. PsA, ankylosing spondylitis: may give with or without MTX or other non-biologic DMARDs.
Children: <18yrs: not established.
Simponi Aria 50mg/4mL soln for IV infusion Adults: RA, PsA, AS: 2mg/kg IV over 30mins at Weeks 0 and 4, then every 8wks thereafter. RA: give with MTX.
Children: <2yrs: not established. PsA, pJIA (2–17yrs): 80mg/m2 at Weeks 0 and 4, then every 8wks thereafter.
infliximab Remicade 100mg/vial pwd for IV infusion after reconsti– tution and dilution Adults: Give by IV infusion over at least 2hrs. RA: 3mg/kg at weeks 0, 2, 6, then every 8wks. May increase to 10mg/kg or give every 4wks. Ankylosing spondylitis: 5mg/kg at weeks 0, 2, 6 then every 6wks. PsA: 5mg/kg at weeks 0, 2, 6, then every 8wks. All: max 5mg/kg in CHF.
Children: Not established.
infliximab-abda Renflexis
infliximab-axxq Avsola
infliximab-dyyb Inflectra
NOTES

Key: AS = Ankylosing spondylitis; DMARD = disease-modifying antirheumatic drug; ERA = Enthesitis-related arthritis; MTX = methotrexate; nr-axSpA = non-radiographic axial spondyloarthritis; PJIA = Polyarticular juvenile idiopathic arthritis; PsA = Psoriatic arthritis; RA = Rheumatoid arthritis; SJIA = Systemic juvenile idiopathic arthritis

* contains alcohol † Not bioequivalent to all other forms of cyclosporine; do not interchange without physician supervision.

Not an inclusive list of medications, indications, and/or dosing details. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling.

(Rev. 12/2023)

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