Arthritis Treatments: DMARDS and Other Immune Modulators

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/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.
azathioprine	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.
	Gengraf†	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.
	Neoral†	100mg/mL	soln*
hydroxy– chloroquine	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: 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 of alternative MTX forms: see full labeling. Children: <2yrs: not established. PJIA: ≥2yrs: initially 10mg/m² SC once weekly; adjust gradually. Use of alternative MTX forms: see full labeling.
	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 full labeling. Children: <2yrs: not established. 2–16yrs: Initially 10mg/m² once weekly. Use of alternative MTX forms: see full labeling.
	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.
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: ≥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, 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.
certolizumab pegol	Cimzia	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. JIA: ≥2yrs: (<63kg): 0.8mg/kg (max 50mg) weekly; (≥63kg): 50mg weekly.
etanercept	Enbrel	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.
golimumab	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. RA: give with MTX. PsA, ankylosing spondylitis: may give with or without MTX or other non-biologic DMARDs. Children: <18yrs: not established.
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-dyyb	Inflectra

Generic	Brand	Strength	Form	Dose
INTERLEUKIN-1 RECEPTOR 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/mL	soln for SC inj	Adults: Not recommended. Children: <2yrs: not established. SJIA: ≥2yrs: (≥7.5kg): 4mg/kg (max 300mg) SC every 4wks.
INTERLEUKIN-12/23 RECEPTOR 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: <18yrs: not established.
INTERLEUKIN-17A RECEPTOR ANTAGONIST
ixekizumab	Taltz	80mg/mL	soln for SC inj	Adults: ≥18yrs: 160mg (given as two 80mg SC inj) at Week 0, then 80mg every 4wks. PsA: may be given alone or in combination with a cDMARD. With coexistent plaque psoriasis: 160mg at Week 0, then 80mg at Weeks 2, 4, 6, 8, 10, and 12, then 80mg every 4wks. Ankylosing spondylitis: may give concomitant cDMARDs, corticosteroids, NSAIDs, and/or analgesics. Children: <18yrs: not established.
secukinumab	Cosentyx	150mg/mL	soln for SC inj	Adults: ≥18yrs: PsA 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 300mg every 4wks if psoriatic arthritis continues. May be administered with or without MTX. 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. Consider 300mg every 4wks if ankylosing spondylitis continues. Children: <18yrs: not evaluated.
secukinumab	Cosentyx	150mg/vial	pwd for SC inj after reconstitution
INTERLEUKIN-6 RECEPTOR INHIBITOR
sarilumab	Kevzara	150mg/1.14mL, 200mg/1.14mL	soln for SC inj	Adults: RA: 200mg SC inj once every 2wks. 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.
tocilizumab	Actemra	162mg/ 0.9mL	prefilled syringe for SC inj
JANUS KINASE INHIBITOR
baricitinib	Olumiant	1mg, 2mg	tabs	Adults: RA: 2mg once daily Children: Not established.
tofacitinib	Xeljanz	5mg, 10mg	tabs	Adults: RA, PsA: 5mg twice daily. Children: Not established.
tofacitinib	Xeljanz XR	11mg	ext-rel tabs	Adults: RA, PsA: 11mg once daily. Children: Not established.
upadacitinib	Rinvoq	15mg	ext-rel tabs	Adults: RA: 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): following a single IV loading dose (based on body wt listed above), give the first 125mg SC inj 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 studied. ≥2yrs: (10–<25kg): 50mg once weekly; (25–<50kg): 87.5mg once weekly; (≥50kg); 125mg once weekly. ClickJect autoinjector: not studied in patients <18yrs.
		50mg/0.4mL, 87.5mg/0.7mL, 125mg/mL	prefilled syringe for SC inj
		125mg/mL	ClickJect autoinjector for SC inj
CD20 ANTIBODY
rituximab	Rituxan	10mg/mL	soln for IV infusion	Adults: 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.
NOTES
Key: cDMARD = conventional disease-modifying antirheumatic drug; JIA = Juvenile idiopathic 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. 5/2020)

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