Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Local Guidance

Shared care guidelines for disease modifying antirheumatic drugs (DMARDs)

Other conventional DMARDs include:

• METHOTREXATE
• CICLOSPORIN
• AZATHIOPRINE
• SULFASALAZINE

Follow the links for information on the above drugs. All these drugs require regular monitoring consult the BNF for details.

Hydroxychloroquine:

Royal College of Opthalmologists Clinical Guideline: Hydroxychloroquine and Chloroquine Retinopathy: Recommendations on Screening, December 2020. To avoid excessive doses in obese people, doses of hydroxychloroquine should be calculated on the basis of lean body weight.

Methotrexate: 

This is given as a ONCE weekly dose as a single dose on the same day of the week. Folic acid 5mg supplements are advisable. There is little evidence with regard to the use and dose. 5 - 10mg is frequently used, with a gap of 24-48 hours between methotrexate and folic acid doses. Methotrexate may also be given by injection for those patients where the oral route is problematic. To avoid dosing errors with weekly low dose methotrexate, see important safety information in the BNF and also refer to the Kent and Medway position statement for prescribing oral methotrexate.

Leflunomide:

It has an active metabolite with a very long half-life which needs to be actively removed, (using colestyramine or activated charcoal), if there are serious adverse effects before starting other DMARDs or before conception. There is increased risk of hepatoxicity (potentially life threatening) with leflunomide in the first 6 months of treatment. Monitor LFTs before treatment and every 2 weeks for the first 6 months then every 8 weeks. See BNF.

Ciclosporin:

It is used when conventional second line therapy is inappropriate or ineffective. There is some evidence that it may retard the rate of erosive progression and improve symptom control in those who only have partial response to methotrexate.

Gold and penicillamine:

warn patients to tell the doctor immediately if sore throat, fever, infection, or non-specific illness, unexplained bleeding and bruising, purpura, mouth ulcers, metallic taste or rashes develop. Also ask patient to report immediately any breathlessness or cough.