Treatment of RA: Dosing regimens for drugs given less frequently than daily

Question 1

Methotrexate (oral)

Answer 1

• 7.5-15 mg Q WK as single (or divided dose); usual max dose is 20-25 mg/wk. Put day of week on label; ask patient for preference
• A divided regimen (e.g., 2 doses 8 h apart) may be used for higher doses (>= 15 mg)

Question 2

Etanercept (Enbrel)

Answer 2

25 mg SC twice a week or 50 mg once a week, may be used with MTX, corticosteroids, NSAIDs

Question 3

Infliximab (Remicade)

Answer 3

• Induction with 3 mg/kg IV infusion at 0, 2, and 6 wk, then 3-10 mg/kg q 4-8 wk
• Use with MTX

Question 4

Adalimumab (Humira)

Answer 4

40 mg SC every 1-2 wk

Question 5

Golimumab (Simponi)

Answer 5

50 mg SC every 4 wk or 2 mg/kg IV at week 0 & 4, then every 8 wk
Approved for use with MTX in RA

Question 6

Certolizumab pegol (Cimzia)

Answer 6

400 mg SC at 0, 2, 4 wk, then 200 mg q 2 wk; consider 400 mg q 4 wk
Approved for use alone or with nonbiologic DMARD in RA

Question 7

Rituximab (Rituxan)

Answer 7

• 1000 mg IV infusion on day 1 and 15
• may be repeated every 24 weeks if needed (not < every 16 wk); premedicate with IV methylprednisolone 100 mg, acetaminophen, & antihistamine before each dose
• if possible, hold antihypertensives 12 h before dose

Question 8

Abatacept (Orencia)

Answer 8

• IV: wt-based; repeated 2 & 4 wk after initial dose, then every 4 wk: <60 kg: 500 mg, 60-100 kg: 750 mg, >100 kg: 1000 mg
• SC: within 24 h of IV loading dose, then weekly; if necessary, can skip IV dose; avoid silicone syringes

Question 9

Tocilizumab (Actemra)

Answer 9

• 4 mg/kg IV infusion over 60 min every 4 wk, may increase to 8 mg/kg
• max 800 mg/infusion or SC: if <100 kg, 162 mg every other wk, may increase to every week; if >=100 kg, 162 mg every wk

Question 10

Sarilumab (Kevzara)

Answer 10

200 mg SC q 2 wk alone or with csDMARD