Arthritis Treatments: DMARDS and Other Immune Modulators all those MABS and CEPTS

Arthritis Treatments: DMARDS and Other Immune Modulators*

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ARTHRITIS TREATMENTS: DMARDS AND OTHER IMMUNE MODULATORS
Generic	Brand	Strength	Form	Dose
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (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 (50−100mg) daily in 1−2 divided doses; after 6−8wks, if needed, may increase by 0.5mg/kg daily increments every 4wks. Max 2.5mg/kg/day. Maintenance: use lowest effective dose. Children: Not recommended.
	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.
		100mg/mL	soln
	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*
hydroxychloroquine	Plaquenil	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	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; max 20mg/day. Children: <18yrs: not recommended.
methotrexate	Otrexup	10mg/0.4mL, 15mg/0.4mL, 20mg/0.4mL, 25mg/0.4mL	soln for SC inj	Adults: 10−25mg once weekly using an oral, IM, SC, or IV form; max 30mg/wk. See entry for full instructions. Children: <2yrs: not established.≥2yrs: Initially 10mg/m² once weekly.
	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, 27.5mg/0.55mL, 30mg/0.60mL	soln for SC inj	Adults: 7.5mg once weekly using oral or SC form. Use of alternative MTX forms: see entry for full labeling. Children: <2yrs: not established. 2–16yrs: Initially 10mg/m² once weekly; Use of alternative MTX forms: see entry for full labeling.
	Rheumatrex	2.5mg	scored tabs	Adults: 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 recommended.≥2yrs: Initially 10mg/m² once weekly; max 20mg/m²/wk.
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.
TUMOR NECROSIS FACTOR (TNF) BLOCKERS
adalimumab	Humira	10mg/0.2mL, 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: <2yrs or <10kg: not recommended. 2−17yrs: (10kg−<15kg): 10mg every other week (10mg prefilled syringe should be used); (15−<30kg): 20mg every other week (20mg prefilled syringe should be used); (≥30kg): 40mg every other week.
certolizumab pegol	Cimzia	200mg/mL	soln for SC inj	Adults: RA, psoriatic arthritis: 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: 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 reconstitution
etanercept	Enbrel	25mg/vial	pwd for SC inj after reconstitution	Adults: 50mg SC once weekly Children: <2yrs: not recommended.JRA: 2−17yrs: 0.8mg/kg weekly; max 50mg/week. ≥63kg: Use adult dose.
		50mg/mL	soln for SC inj
golimumab	Simponi	50mg/0.5mL	soln for SC inj	Adults: 50mg SC once monthly. May continue to use corticosteroids, non-biologic DMARDs, and/or NSAIDs during treatment. Children: <18yrs: not established.
	Simponi Aria	50mg/4mL	soln for IV infusion	Adults: Infuse over 30min. 2mg/kg IV at Weeks 0 and 4, then every 8wks thereafter. May continue to use corticosteroids, non-biologic DMARDs, and/or NSAIDs during treatment. Children: <18yrs: not established.
infliximab	Remicade	100mg/vial	pwd for IV infusion after reconstitution 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. Psoriatic arthritis: 5mg/kg at weeks 0, 2, 6, then every 8wks. All: max 5mg/kg in CHF. Children: Not recommended.
Generic	Brand	Strength	Form	Dose
INTERLEUKIN-1 RECEPTOR ANTAGONIST
anakinra	Kineret	100mg/0.67mL	soln for SC inj	Adults: ≥18yrs: 100mg SC once daily Children: <18yrs: not recommended.
canakinumab	Ilaris	180mg/vial	pwd for SC inj after reconstitution	Adults: Not recommended. Children: <2yrs: not recommended. ≥2yrs: (≥7.5kg): Give 4mg/kg via SC inj every 4wks; max 300mg
INTERLEUKIN-12/23 RECEPTOR ANTAGONIST
ustekinumab	Stelara	45mg/0.5mL, 90mg/1mL	soln for SC inj	Adults: ≥18yrs: 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: <18yrs: not evaluated.
INTERLEUKIN-17A RECEPTOR ANTAGONIST
secukinumab	Cosentyx	150mg/mL	soln for SC inj	Adults: ≥18yrs: Psoriatic arthritis with coexistent plaque psoriasis: 300mg (given as two 150mg inj) SC at Weeks 0, 1, 2, 3, and 4 then 300mg every 4wks. Other psoriatic arthritis (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 a 300mg dose if psoriatic arthritis continues. Ankylosing spondylitis(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: <18yrs: not evaluated.
		150mg/vial	pwd for SC inj after reconstitution
INTERLEUKIN-6 RECEPTOR INHIBITOR
tocilizumab	Actemra	20mg/mL	soln for IV infusion after dilution	Adults: RA: IV: Initially 4mg/kg every 4wks, then 8mg/kg every 4wks based on clinical response. Doses >800mg/infusion: not recommended.SC: <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: RA: not established. SJIA, PJIA: <2yrs or SC administration: not studied. ≥2yrs: Give once every 2wks (SJIA) or once every 4wks (PJIA) as a 60‑min IV infusion. SJIA: <30kg: 12mg/kg. PJIA:<30kg: 10mg/kg. Both: ≥30kg: 8mg/kg.
		162mg/0.9mL	prefilled syringe
JANUS KINASE INHIBITOR
tofacitinib	Xeljanz	5mg	tabs	Adults: 5mg twice daily Children: Not established.
	Xeljanz XR	11mg	ext-rel tabs	Adults: 11mg once daily. Children: Not established.
PHOSPHODIESTERASE 4 INHIBITOR
apremilast	Otezla	10mg, 20mg, 30mg	tabs	Adults: Active psoriatic arthritis: 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 reconstitution and dilution	Adults: IV regimen: Give as IV infusion over 30 min at weeks 0, 2, and 4, then every 4wks. <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. Children: <6yrs: not recommended.<6−17yrs: (<75kg): 10mg/kg. (≥75kg): Use adult dose; max 1g. Give as an IV infusion over 30min at weeks 0, 2, and 4, then every 4wks thereafter.
		125mg/mL	soln for SC inj
CD20 ANTIBODY
rituximab	Rituxan	10mg/mL	soln for IV infusion	Adults: Give glucocorticoids 30min prior to each infusion. Concomitant MTX therapy: give two 1000mg IV infusions separated by 2wks. Subsequent courses should be given every 24wks or based on response, but not sooner than every 16wks. Children: Not established.
NOTES
Key: RA = Rheumatoid arthritis; MTX = methotrexate; JIA = Juvenile rheumatoid 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 * http://www.rheumatologyadvisor.com/clinical-charts/arthritis-treatments-dmards-and-other-immune-modulators/article/460209/ (Rev. 5/2016)