Medications by Diseases

Pharmacotherapy choice is based on organ involvement and severity of disease.

General SLE Meds

• Anifrolumab
• Azathioprine
• Belimumab
• Cyclophosphamide
• Hydroxychloroquine
• Methotrexate
• Mycophenolate
• Rituximab
• NSAIDs: can be used for arthralgias
• Local or systemic glucocorticoids for acute exacerbations

Lupus Nephritis Therapies

• Systemic steroids
• Azathioprine, PO
• Belimumab
• Calcineurin inhibitors:
  • Tacrolimus, PO
  • Voclosporin, PO
• Cyclophosphamide
• Mycophenolate, PO
• Rituximab

Sun protection is key!

Initial Treatment

• Steroids:
  • PO/IV prednisone equivalent to 1-2 mg/kg/day, then slow taper over months
  • Consider pulse steroids in severe patients
• IVIG: 1-2 gm/kg/day

Long-Term Immunosuppression per Rheumatology

• Azathioprine
• JAK inhibitors
• Methotrexate
• Mycophenolate
• Rituximab
• Tacrolimus
• Tocilizumab
• Physical therapy and rehabilitation are key

Short-Term Therapy

Quick onset, unsafe in high doses, long term

• NSAIDs – do not slow/modify disease
• Glucocorticoids

Long-Term Therapy

DMARD = disease-modifying anti-rheumatic drugs (this means these medications help slow/modify the disease progression)

Conventional Disease Modifying (cDMARD)

Small molecules so can be dosed orally (PO)

• Azathiprine: QD or BID PO
• Hydroxychloroquine: QD or BID PO
• Leflunomide: QD PO
• Methotrexate: Weekly PO or SQ
• Sulfasalazine: BID PO

Biologic Disease Modifying (bDMARD)

Large molecules so have to be injections: subcutaneous (SQ) or intravenous (IV) administration

• TNF-alpha inhibitors
  • Adalimumab SQ
  • Certolizumab pegol SQ
  • Etanercept SQ
  • Golimumab, SQ or IV
  • Infliximab IV
• B-cell targeting medications
  • Rituximab, IV
• IL-6 axis inhibitors
  • Sarilumab, SQ
  • Tocilizumab, SQ or IV
• CTLA4 agonist
  • Abatacept, SQ or IV

Targeted Synthetic DMARD (tsDMARD)

Small molecule so oral but unlike the conventional DMARDs, they are targeted to a particular molecule

• JAK inhibitors
  • Baricitinib
  • Tofacitinib
  • Upacitinib

Occupational therapy/physical therapy are vital.

Peripheral Arthritis

• NSAIDs
• Oral agents:
  • Sulfasalazine
  • Methotrexate
  • Apremilast, PO – for psoriatic arthritis
  • JAK inhibitors
• Biologics:
  • TNF-alpha inhibitors:
    • Adalimumab SQ
    • Certolizumab pegol SQ
    • Etanercept SQ (do not use for uveitis or IBD)
    • Golimumab SQ
    • Infliximab IV
  • IL-12 and/or IL-23 inhibitors:
    • Guselkumab
    • Risankizumab
    • Ustekinumab
  • IL-17 inhibitors:
    • Secukinumab
    • Ixekizumab

Axial Arthritis

• NSAIDs first line
• TNF inhibitors
• JAK inhibitors
• IL-17 inhibitors

Physical therapy is important! Collaboration with dermatology, gastroenterology, ophthalmology, etc., are key for spondyloarthritis.

• Skin fibrosis
  • Mycophenolate: can slow skin progression
  • Methotrexate
• Raynaud’s:
  • Calcium channel blockers
  • Topical nitroglycerin
  • PDE-5 inhibitors
  • Prostacyclin analogues
  • Endothelin receptor antagonists
  • SSRI fluoxetine
• Arthritis:
  • DMARDs: hydroxychloroquine, methotrexate
• ILD:
  • Mycophenolate: less toxic than cyclophosphamide
  • Cyclophosphamide
  • Anti-fibrotics
• SRC: ACEi
• pHTN: PDE-5i, endothelin receptor antagonists, prostacycline analogues, etc.
• GERD/dysphagia: H2 blockers, PPI

Collaboration with dermatology, pulmonary, pHTN specialist, gastroenterology, etc. are key for
systemic sclerosis.

ANCA-Associated Vasculitis

• Usually with rheumatology supervision
• Two-part approach: induction and maintenance

Induction

• High doses of steroids with taper
• Cyclophosphamide
• Rituximab
• Methotrexate
• +/- plasma exchange
• Avacopan as add-on therapy for those with severe active disease

Maintenance Choices

• Azathioprine
• Methotrexate (works well for sinonasal/upper airway disease)
• Rituximab
  Additional therapy
• PJP prophylaxis: trimethoprim-sulfamethoxazole, dapsone, etc.
• Vit D, calcium

Giant Cell Arteritis

• Systemic steroids with glucocorticoids
• IL6 receptor inhibitor with tocilizumab
• Low dose ASA

• IVIG
• Plasmapharesis