New RA Management Guidelines: A Quick and Easy Guide
The Basics:
• In cases of MTX contraindications or early intolerance, sulfasalazine or leflunomide should be considered as part of the initial treatment approach.
• Contraindications to MTX include hepatic or renal disease; MTX-induced lung disease is also a concern.
• Optimal sulfasalazine dosing is 3-4 g/day as enteric-coated tablets; the usual leflunomide dose is 20 mg/day.
• Antimalarials, including hydroxychloroquine and chloroquine, can be considered as monotherapy or part of combination therapy, primarily in patients with low disease activity.
• MTX intolerance within 6 weeks should be viewed as a contraindication rather than treatment failure.
Changes: MTX intolerance has been modified with the word "early" to indicate that intolerance to the drug within 6 weeks should be viewed as a contraindication rather than a failure of treatment. The prior recommendation 4 listed injectable gold salts as a possible MTX alternative. Although gold salts have established efficacy on the basis of high-quality evidence, they have been removed from their formerly prominent position among possible RA treatment because no study has evaluated intramuscular gold since the previous systematic literature review was conducted.
The Bottom Line: Several other DMARDs can be used in lieu of MTX, either as monotherapy or in combination.
MTX Contraindications
The Basics:
• In cases of MTX contraindications or early intolerance, sulfasalazine or leflunomide should be considered as part of the initial treatment approach.
• Contraindications to MTX include hepatic or renal disease; MTX-induced lung disease is also a concern.
• Optimal sulfasalazine dosing is 3-4 g/day as enteric-coated tablets; the usual leflunomide dose is 20 mg/day.
• Antimalarials, including hydroxychloroquine and chloroquine, can be considered as monotherapy or part of combination therapy, primarily in patients with low disease activity.
• MTX intolerance within 6 weeks should be viewed as a contraindication rather than treatment failure.
Changes: MTX intolerance has been modified with the word "early" to indicate that intolerance to the drug within 6 weeks should be viewed as a contraindication rather than a failure of treatment. The prior recommendation 4 listed injectable gold salts as a possible MTX alternative. Although gold salts have established efficacy on the basis of high-quality evidence, they have been removed from their formerly prominent position among possible RA treatment because no study has evaluated intramuscular gold since the previous systematic literature review was conducted.
The Bottom Line: Several other DMARDs can be used in lieu of MTX, either as monotherapy or in combination.
SHARE
