Below are the major categories of rheumatology medications by disease and some examples of meds in each category.

Acute Symptom Reduction

  • NSAIDs
  • Colchicine
  • Glucocorticoids
  • IL-1 axis inhibitors
    • Anakinra
    • Canakinumab
  • Intra-articular steroids
  • Systemic glucocorticoids

Long-Term Treatment

  • Gout (urate-lowering therapies)
    • Allopurinol
    • Febuxostat
    • Pegloticase
    • Probenecid
  • Pseudogout
    • Colchicine
    • Hydroxychloroquine can be considered

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