Conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) for treatment of rheumatoid arthritis
Australia & New Zealand Musculoskeletal Clinical Trials Network (ANZMUSC), 2023Bakker, 2007Escalas, 2012Hazlewood, 2016Jacobs, 2012Smolen, 2020
Disease-modifying antirheumatic drugs (DMARDs) are used to reduce or eradicate synovitis, improve pain and prevent joint damage in RA. Therapy with conventional synthetic DMARDs (csDMARDs) should be started as soon as possible. Drugs classified as csDMARDs for use in RA include methotrexate, leflunomide, sulfasalazine and hydroxychloroquine.
Conventional synthetic DMARDs are prescribed by specialists to induce and maintain clinical remission in patients with RA. Therapy may comprise a single csDMARD (usually methotrexate, unless contraindicated) or a combination of up to 3 csDMARDs (‘triple therapy’, usually including methotrexate, sulfasalazine and hydroxychloroquine), with or without a low-dose oral corticosteroid.
If csDMARD therapy is started, use a ‘treat-to-target’ approach aiming for clinical remissionSmolen, 2020 and monitor disease activity regularly. A response to csDMARDs usually will be apparent within 12 weeks. If the target is not achieved despite an adequate dose of the first csDMARD, consider switching to a different regimen, or adding a second or third csDMARD to an existing regimen.
Advice about initial DMARD therapy for RA is available from An Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis: Initial DMARD therapy for people with rheumatoid arthritis1.
Patients with significant kidney or liver impairment may require csDMARD dose adjustments. For considerations on the management of patients taking csDMARDs (including monitoring, screening for infection, and vaccination), see:
- Considerations before starting immunomodulatory therapy
- Considerations during immunomodulatory therapy.
Patients who have an inadequate response to csDMARDs may require combination therapy with a biological or targeted-synthetic DMARD (b/tsDMARD).
For advice about dose reduction or discontinuation of csDMARDs, see Dose reduction and discontinuation of csDMARDs, and for advice about pausing csDMARDs for surgery, see Perioperative use of csDMARDs.
Some immunomodulatory drugs used in the treatment of RA have potentially adverse effects on reproductive health in both females and males. The choice of immunomodulatory drugs needs careful consideration in people of childbearing potential, including children and adolescents. See Immunomodulatory drug use and reproductive health for more details.