Which medications in the drug class DMARDs, Other are used in the treatment of Rheumatoid Arthritis (RA)?

Updated: Feb 07, 2020
  • Author: Howard R Smith, MD; Chief Editor: Herbert S Diamond, MD  more...
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DMARDs, Other

DMARDs represent the most important measure in the successful treatment of rheumatoid arthritis. These agents can retard or prevent disease progression and, thus, joint destruction and subsequent loss of function. Successful DMARD therapy may eliminate the need for other anti-inflammatory or analgesic medications; however, until the full action of DMARDs takes effect, anti-inflammatory or analgesic medications may be required as bridging therapy to reduce pain and swelling.

Leflunomide (Arava)

Leflunomide is indicated for the treatment of active RA to reduce signs and symptoms, inhibit structural damage and improve physical function. Corticosteroids, aspirin, or other NSAIDs may be continued during leflunomide use. Leflunomide is contraindicated in women who are or may become pregnant.

Leflunomide is a pyrimidine synthesis inhibitor that blocks autoimmune antibodies and reduces inflammation. It also inhibits dihydroorotate dehydrogenase, an enzyme in the de novo pyrimidine synthesis pathway and has antiproliferative activity. 

Sulfasalazine (Azulfidine, Azulfidine EN-tabs)

Sulfasalazine (SSZ) is indicated for the treatment of patients with RA who have had an inadequate response to salicylates or other NSAIDs. It acts locally to decrease inflammatory response and systemically inhibits prostaglandin synthesis.

SSZ delayed-release tablets do not have an immediate response; therefore, concurrent treatment with NSAIDs or other analgesics is recommended at least until the effect of the delayed-release tablets is apparent. The initial dosage is 0.5-1 g/day. The dosage can be adjusted to a dose of 3 g/day after 12 weeks if an adequate clinical response is not seen.

Hydroxychloroquine (Plaquenil)

Hydroxychloroquine (HCQ) is approved for the treatment of acute or chronic RA. The initial dosage is 400-600 mg/day; dosages should be computed on the basis of patient body weight. If a good clinical response is seen over a period of 4 to 12 weeks, the dosage can be reduced by 50% and continued at a level of 200-400 mg/day. The risk of retinopathy is greater when this dosage is exceeded. It should be noted that each 200 mg tablet contains only 155 mg of active drug.

Patients must have a baseline eye examination (including color and vision testing, funduscopic examination, and visual-field testing) performed before starting HCQ therapy. Most rheumatologists recommend an HCQ eye examination every 6-12 months.

Rituximab (Rituxan)

Rituximab is most often used in combination with methotrexate (MTX). It has been shown to be effective at reducing signs and symptoms in adult patients with moderately to severely active RA who have had an inadequate response to therapy with 1 or more tumor necrosis factor (TNF) antagonists. Treatment with rituximab may deplete CD20+ B cells. The usual regimen consists of 2 intravenous (IV) infusions of 1000 mg, separated by 2 weeks, in combination with MTX.

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