Other csDMARDs for rheumatoid arthritis

Leflunomide is often used as a first-line drug for RA if methotrexate is contraindicated or not toleratedSmolen, 2020. It may also be used in combination therapyOsiri, 2003Smolen, 2020. Leflunomide has a long half-life and may be used less than once daily; however, for RA, the usual maintenance dosage is:

For additional considerations specific to leflunomide use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

SulfasalazineSuarez-Almazor, Belseck, Shea, Wells, 2000 and hydroxychloroquineSuarez-Almazor, Belseck, Shea, Homik, 2000 are considered less effective and usually used as second- or third-line drugs or in combination therapy for RA (eg ‘triple therapy’ comprising methotrexate plus sulfasalazine plus hydroxychloroquine)Smolen, 2020. Monotherapy with sulfasalazine or hydroxychloroquine may be used if the patient has less-severe disease, or when other agents are contraindicated (eg during pregnancy).

The usual dosage of sulfasalazine in RA is:

For additional considerations specific to sulfasalazine use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

The usual dosage of hydroxychloroquine in RA is:

For additional considerations specific to hydroxychloroquine use, see Specific considerations for use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs).

If remission is not achievable or significant disease activity persists after trialling csDMARD combination therapy, specialist review is required for consideration of a b/tsDMARD; see b/tsDMARDs for RA for more information.