| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Methotrexate[1] | Conventional synthetic DMARD (anti-folate) | Start 10–15 mg PO/SC weekly with folic acid 5 mg weekly (different day); titrate to 20–25 mg weekly | — | First-line for moderate-severe RA; SC route improves bioavailability; LFT and FBC every 2 weeks initially then 8–12 weekly; alcohol restriction; teratogen — contraception |
| Hydroxychloroquine[1] | Antimalarial / immunomodulator | 200–400 mg PO daily (maximum 5 mg/kg actual body weight) | — | Mild RA monotherapy or combination; baseline retinal exam and annual screening from year 5; safe in pregnancy |
| Sulfasalazine[1] | 5-aminosalicylate | Start 500 mg PO BD, titrate to 1 g BD-TDS | — | First-line alternative or in pregnancy; FBC and LFT monitoring; sulfa allergy; safe with hydroxychloroquine in triple therapy |
| Leflunomide[1] | Conventional synthetic DMARD (DHODH inhibitor) | 20 mg PO daily (loading 100 mg × 3 days then 20 mg) | — | Alternative to methotrexate; LFT and BP monitoring; long half-life — colestyramine washout for stopping; teratogen |
| Anti-TNF (etanercept, adalimumab, infliximab, certolizumab, golimumab)[1] | TNF-alpha inhibitor (biologic) | Etanercept 50 mg SC weekly; adalimumab 40 mg SC every 2 weeks; infliximab 3 mg/kg IV at 0, 2, 6 weeks then every 8 weeks | Per local protocol | Add when conventional DMARD inadequate; latent TB and HBV screen; certolizumab preferred in pregnancy (no placental transfer); biosimilars widely available |
| Tocilizumab or sarilumab[1] | IL-6 receptor inhibitor | Tocilizumab 162 mg SC weekly; sarilumab 200 mg SC every 2 weeks | — | Useful in monotherapy where methotrexate not tolerated; lipid increase, neutropenia, GI perforation risk |
| Rituximab[1] | Anti-CD20 monoclonal antibody | 1 g IV × 2 doses 2 weeks apart, repeat at 6 months | — | Seropositive RA failing TNF inhibitor; HBV screen and prophylaxis; vaccinate before; long-lasting immunosuppression |
| JAK inhibitor (tofacitinib, baricitinib, upadacitinib)[1] | Janus kinase inhibitor | Tofacitinib 5 mg PO BD; baricitinib 4 mg PO daily; upadacitinib 15 mg PO daily | — | Oral biologic alternative; ORAL Surveillance signal — increased CV events, malignancy, VTE in some patients ≥50; reserve for second-line; latent TB and HBV screen |
Treat-to-target conventional synthetic, biological, and targeted synthetic DMARD pathway for adults with rheumatoid arthritis.