Analgesics (Non-Opioid)

Anilide
Drug	Dosage	Remarks
Paracetamol¹ (Acetaminophen)	325-650 mg PO 4-6 hourly or 500-1,000 mg PO 6-8 hourly Max dose: 4 g/day	Adverse Reactions Hematologic effects (anemia, neutropenia); Dermatologic effect (rash); Hepatic effects (increased bilirubin, alkaline phosphatase); Metabolic effects (increased uric acid, glucose); Other effects (nephropathy, anaphylaxis) Special Instructions Avoid use in patients with severe hepatic or active liver disease Used with caution in patients with chronic malnutrition, severe renal impairment, alcoholic liver disease, glucose-6-phosphate dehydrogenase (G6PD) deficiency
Salicylic Acid & Derivative
Aspirin (Acetylsalicylic acid)	300-900 mg PO 4-6 hourly Max dose: 4 g/day	Adverse Reactions GI effects (nausea/vomiting, dyspepsia, ulceration, hematemesis); Hematologic effects (iron-deficiency anemia after long-term use, hypoprothrombinemia); Dermatologic effects (urticaria, angioedema); Hypersensitivity reactions (bronchospasm, dyspnea); Other effect (hepatotoxicity) Salicylism (dizziness, tinnitus, deafness, sweating, nausea/vomiting, headache, confusion) may occur after repeated use of large doses Special Instructions May be given with food to decrease GI effects Avoid use in patients with hemophilia or other hemorrhagic disorders, history of allergy to other NSAIDs, severe renal or hepatic impairment, pregnancy (especially third trimester) Use with caution in patients prone to dyspepsia, with gastric ulcer, asthma or allergic disorders, renal or hepatic impairment, dehydration, uncontrolled hypertension, G6PD deficiency, diabetes mellitus (DM) Aspirin should be stopped several days before surgery

¹Combinations with various analgesics are available. Please see the latest MIMS for specific formulations and prescribing information.

Analgesic (Opioid)

Drug

Dosage

Remarks

Tramadol¹

50-100 mg PO 4-6 hourly
Extended-release: 50-100 mg PO 12-24 hourly
Max dose: 400 mg/day

Adverse Reactions

GI effects (nausea/vomiting, constipation, dry mouth); CNS effects (drowsiness, confusion, dizziness, headache, changes in mood); CV effects (bradycardia, tachycardia, palpitations)
Large doses may cause resp depression/failure, renal failure, hypotension, deepening coma

Special Instructions

Avoid use in patients with acute respiratory depression, obstructive airway disease, acute alcoholism, convulsive disorder, head injuries, increased intracranial pressure, at risk of paralytic ileus, or in patients who require mental alertness (eg driving, operating machines)
Use with caution in patients with hypothyroidism, asthma, renal or hepatic impairment, adrenocortical insufficiency, prostatic hyperplasia, hypotension, shock, inflammatory or obstructive bowel disease, myasthenia gravis

¹Combination with Paracetamol is available. Please see the latest MIMS for specific formulations and prescribing information.

Corticosteroid Hormones - Intra-Articular (IA)

Drug	Dosage	Remarks
Betamethasone (Betamethasone Na phosphate)	Small joints: 0.25-0.5 mL IA Medium joints: 0.5-1.0 mL IA Large joints: 1-2 mL IA	Adverse Reactions Local effects (post-injection flare, sterile abscess, thrombophlebitis) Special Instructions Systemic absorption should always be considered Use with caution in patients with preexisting psychiatric conditions, heart failure, DM, GI diseases, hepatic impairment including cirrhosis, myasthenia gravis, cataracts and/or glaucoma, osteoporosis, renal impairment, history of seizure disorder, thyroid disease, following acute myocardial infarction (MI)
Dexamethasone	0.2-6 mg/dose IA once every 3-5 days for bursae or once every 2-3 weeks for joints or Small joints: 0.6-1 mg IA Large joints: 1.6-4 mg IA
Methylprednisolone (Methylprednisolone acetate)	Small joints: 4-10 mg/dose IA Medium joints: 10-40 mg/dose IA Large joints: 20-80 mg/dose IA
Prednisolone	5-25 mg/dose IA at each site every 1-3 weeks
Triamcinolone (Triamcinolone acetonide)	Small joints: 2.5-5 mg IA Max dose: 10 mg Large joints: 5-15 mg IA Max dose: 40 mg

Corticosteroid Hormones - Oral

Drug	Dosage	Remarks
Betamethasone	1.5-3 mg PO 24 hourly Maintenance dose: 0.5-1.5 mg/day in divided doses, reduced by 0.25 mg every 2-3 days until the lowest dosage required to maintain an adequate clinical response is achieved	Adverse Reactions Endocrine effects (adrenal suppression, osteoporosis, DM); Other effects (psychiatric disturbances, cataracts, hypertension, skin atrophy, increased susceptibility to infection, impaired healing) Special Instructions Avoid in patients with acute viral disease, systemic fungal infection, duodenal and peptic ulcer, live virus vaccination Use with caution in patients with heart failure, acute MI, DM, GI diseases, hepatic/renal impairment, myasthenia gravis, seizure disorder, osteoporosis, thyroid disease, cataracts, glaucoma
Dexamethasone	0.75-9 mg/day PO in 2-4 divided doses or Active RA with severe progressive course form: 12-16 mg PO 24 hourly if running at fast destructive forms 6-12 mg PO 24 hourly if with extra-articular manifestations
Methylprednisolone	4-48 mg PO 24 hrly as single dose or in divided doses or Moderate RA: 4-8 mg/day PO divided 6 hourly Moderately severe RA: 8-12 mg/day PO divided 6 hourly Severe RA: 12-16 mg/day PO divided 6 hourly or 1 g IV 24 hourly x 1-4 days or 1 g IV pulse over 30 minutes once monthly x 6 months
Prednisone	5-10 mg PO 24 hourly May increase to 15-20 mg PO 24 hourly	Adverse Reactions Hematologic effects (leukocytosis, lymphopenia, eosinopenia, polycythemia); Endocrine effect (adrenocortical insufficiency); CV/Renal effects (blood pressure [BP] elevation, Na/water retention, increased K excretion); Other effect (increased susceptibility to infection) Special Instructions Initiate therapy with lowest possible dose Avoid use in patients with systemic fungal infection, acute viral infections (ie herpes zoster, keratitis, varicella) Use with caution in patients with CHF, hypertension, renal insufficiency, hypothyroidism, peptic ulcer, diverticulitis, intestinal anastomoses, ulcerative colitis, increased risk of osteoporosis, history of emotional instability/psychotic tendencies, narrow-/wide-angle glaucoma Monitor intraocular pressure, creatine kinase, bone mineral density during therapy
Prednisolone	Initial dose: 5-7.5 mg PO 24 hourly May be increased by 1 mg at few weeks intervals Max dose: 60 mg/day
Triamcinolone	4-48 mg PO 24 hourly as single dose or in divided doses

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Biological Agents - Anti-TNF
Drug	Dosage	Remarks
Adalimumab (Adalimumab-adaz, Adalimumab-adbm, Adalimumab-afzb, Adalimumab-atto, Adalimumab-bwwd)	40 mg SC as single dose every other week May increase dosing frequency to 40 mg/week or 80 mg every other week if not taken concomitantly with Methotrexate	Adverse Reactions CNS effects (headache, dizziness); GI effects (abdominal discomfort, nausea/vomiting); Other effect (local injection site reaction) Allergic/hypersensitivity reactions rarely occur Hypersensitivity reaction may occur within 2 hours of Infliximab infusion Rare cases of autoimmune disorder have been reported Serious and potentially fatal infections (eg bacterial, mycobacterial, viral, fungal infections) have been reported Reports of TB reactivation of latent infection and new infection have been noted Rare reactivation of hepatitis B virus infection has occurred Lymphoma and other malignancies There have been reports of increased risk of hepatosplenic T-cell lymphoma (HSTCL) development, particularly in adolescents and young adults Severe hepatic reactions have been reported during treatment with Infliximab Special Instructions Do not give to patients with active chronic or localized infection Use with caution in patients with hematologic disorders, heart failure, history of new/recurrent infections, with conditions that predispose to infection (eg DM), demyelinating CNS disorders Infliximab should be used with caution in patients with history of seizure Medication and equipment for immediate management of hypersensitivity reactions should be available Monitor for signs and symptoms of malignancy (eg splenomegaly, hepatomegaly, abdominal pain, persistent fever, night sweats, weight loss) Temporarily discontinue Etanercept use in patients with significant exposure to varicella virus May treat with varicella zoster immunoglobulin Discontinue Infliximab use in patients developing significant CNS adverse reaction, jaundice or liver enzyme ≥5x ULN Hepatitis and TB screening is recommended prior to treatment Update immunization status of the patient prior to start of therapy
Certolizumab pegol	Initial dose: 400 mg/day SC given as single injection or 2 injections (200 mg each) 24 hourly at week 0, 2 and 4 Maintenance dose: 200 mg SC every 2 weeks or 400 mg SC every 4 weeks
Etanercept (Etanercept-szzs, Etanercept-ykro)	25 mg SC twice weekly (72-96 hours apart) or 50 mg SC once weekly
Golimumab	50 mg SC once a month or Initial dose: 2 mg/kg IV infusion over 30 minutes, given in combination with Methotrexate Subsequent dose: Given 4 weeks later and then every 8 weeks thereafter
Infliximab (Infliximab-abda, Infliximab-axxq, Infliximab-dyyb, Infliximab-qbtx)	In combination with Methotrexate: 3 mg/kg IV infusion 24 hourly at week 0, 2 and 6, then every 8 weeks thereafter Dose may be increased up to 10 mg/kg
Biological Agents - Non-TNF
Abatacept	<60 kg: 500 mg 60-100 kg: 750 mg >100 kg: 1,000 mg Dose according to body weight and administered as a 30-minutes IV infusion Repeat dose at 2 and 4 weeks after the first infusion then every 4 weeks thereafter	Adverse Reactions CNS effects (headache, dizziness, fever); GI effects (abdominal discomfort, nausea); Other effects (infection, hypertension, rash, back pain, infusion-related reaction) Allergic reactions may occur Drug use may affect defenses against malignancies Clinical trials have noted increased risk for lymphoma and lung cancer Special Instructions Use with caution in patients with chronic obstructive pulmonary disease (COPD), with history of new/recurrent infections, with conditions that predispose patient to infection Hepatitis and TB screening prior to treatment Update immunization status of the patient prior to start of therapy
Rituximab (Rituximab-abbs, Rituximab-pvvr)	In combination with Methotrexate: 1,000 mg IV infusion on day 1 and 15 Subsequent doses may be administered every 24 weeks or based on clinical evaluation, but not sooner than every 16 weeks	Adverse Reactions CV effects (hypertension, edema); CNS effects (fever, fatigue, headache); Dermatologic effects (rash, pruritus, angioedema); GI effects (nausea, diarrhea, weight gain, abdominal pain) New/reactivation of viral infections, infusion-related reactions, hypersensitivity reactions and mucocutaneous reactions have been reported Special Instructions Administer Methylprednisolone 100 mg IV or its equivalent 30 minutes prior to each infusion to reduce incidence and severity of infusion reactions Use with caution in patients with pre-existing CV and pulmonary disease, patients with evidence of previous HBV infection (eg HBsAg positive regardless of antibody status, HBsAg negative but anti-HBc positive) Vaccination with live-virus vaccines is not recommended Hepatitis screening is recommended prior to treatment For patients initiating Rituximab who are anti-HBc positive (regardless of HBsAg status), prophylactic antiviral therapy for hepatitis B infection is recommended over frequent monitoring alone
Sarilumab	200 mg SC 24 hourly every 2 weeks	Adverse Reactions Hematologic effects (neutropenia, thrombocytopenia); Respiratory effects (upper respiratory tract infection [URTI], nasopharyngitis); Metabolic effects (hypercholesterolemia, hypertriglyceridemia, increased transaminases); Other effects (urinary tract infection [UTI], oral herpes, injection site pruritus and erythema) Special Instructions Use with caution in patients with severe renal impairment and hepatic impairment, active infection, GI perforation, increased risk of malignancies, hypersensitivity reactions; increased risk for CV disorders Monitor LFT, lipid profile, neutrophils, platelet count
Tocilizumab	4-8 mg/kg IV infusion over 1 hour every 4 weeks or >100 kg: 800 mg IV infusion over 1 hour every 4 weeks or <100 kg: 162 mg SC once every other week May increase to 162 mg SC once weekly based on clinical response ≥100 kg: 162 mg SC once weekly	Adverse Reactions CV effects (hypertension, edema); Dermatologic effects (pruritus, urticaria); CNS effects (headache, dizziness); GI effects (abdominal discomfort, stomatitis, weight gain); Other effects (neutropenia, thrombocytopenia, increased triglycerides, elevated LFT, infusion-related reactions) One case of fatal anaphylaxis has been reported Serious and potentially fatal infections (eg bacterial, mycobacterial, viral, fungal infections) have been reported Reports of TB both reactivation of latent infection and new infection have been noted Special Instructions Use is not recommended in patients with hepatic impairment Use with caution in patients with demyelinating CNS disorders or with risk of GI perforation Latent TB screening is recommended prior to treatment
Conventional Synthetics
Auranofin	3 mg PO 12 hourly or 6 mg PO 24 hourly May increase dose to 3 mg PO 8 hourly after 6 months Max dose: 9 mg/day A lower initial dose of 3 mg PO 24 hourly may be used to reduce incidence of adverse effects	Adverse Reactions Dermatologic effects (rash, pruritus, lesions on the mucous membrane); GI effects (persistent diarrhea, ulcerative colitis, stomatitis, anorexia); Hematologic effects (anemia, agranulocytosis); Other effects (alopecia, elevated LFT, hematuria, proteinuria) Special Instructions Contraindicated in patients with renal disease, history of blood dyscrasias, CHF, exfoliative dermatitis, necrotizing enterocolitis, history of anaphylactic reactions Discontinue therapy if platelet count falls <100,000/mm³, WBC count is <4,000 or if granulocyte count is <1,500/mm³
Azathioprine	1 mg/kg/day PO divided 12-24 hourly May increase dose by 0.5 mg/kg/day after 6-8 weeks of treatment at 4-week intervals Max dose: 2.5 mg/kg/day	Adverse Reactions CNS effects (fever, malaise); GI effects (nausea/vomiting, diarrhea); Hematologic effects (leukopenia, thrombocytopenia); Other effects (increased LFT, myalgia, rarely pancreatitis) Increased risk of neoplasia with chronic use Special Instructions Use with caution in patients with hepatic or renal impairment, with thiopurine S-methyltransferase (TPMT) deficiency There have been reports of increased risk of HSTCL development, particularly in adolescents and young adults Monitor for signs and symptoms of malignancy (eg splenomegaly, hepatomegaly, abdominal pain, persistent fever, night sweats, weight loss) Monitor CBC and platelets, LFT, total bilirubin, TPMT genotyping or phenotyping
Ciclosporin (Cyclosporine)	3 mg/kg/day PO divided 12 hourly x 6 weeks Max dose: 5 mg/kg/day or 2.5 mg/kg/day PO divided 12 hourly x 6-8 weeks May increase dose by 0.5-0.75 mg/kg/day after 6-8 weeks then after 12 weeks Max dose: 4 mg/kg/day Discontinue treatment if no response after 4 months of use	Adverse Reactions GI effects (abdominal pain, diarrhea, nausea, dyspepsia); CNS effects (tremors, headache); CV effects (hypertension, edema); Other effects (gingival hyperplasia, hirsutism, hypertrichosis, renal dysfunction, nephropathy, elevated creatinine, increased triglycerides, infection) Special Instructions Avoid prolonged sun exposure, tanning booths and sunlamps Avoid in patients with renal dysfunction, uncontrolled hypertension, uncontrolled infections, persistently raised creatinine, malignancy, porphyria Monitor renal and hepatic function, BP, serum electrolytes and lipids regularly Vaccination with live-virus vaccines is not recommended Commercially available oral products differ in their bioavailability; use caution when switching from one product to another
Hydroxychloroquine	Initial dose: 400-800 mg PO 12-24 hourly Maintenance dose: 200-400 mg PO 24 hourly Max dose: 6.5 mg/kg/day	Adverse Reactions CNS effects (dizziness, headache, nervousness, seizure, vertigo); Dermatologic effects (alopecia, rash); GI effects (nausea/vomiting, abdominal pain); Other effects (visual symptoms, muscle weakness) Special Instructions Use with caution in patients with hepatic or renal impairment, G6PD deficiency, psoriasis, porphyria Perform baseline ophthalmologic exam and every 3 months Test periodically for muscle weakness Baseline assessment of hepatic and renal function is recommended
Leflunomide	Loading dose: 100 mg PO 24 hourly x 3 days Maintenance dose: 10-20 mg PO 24 hourly	Adverse Reactions GI effects (diarrhea, nausea/vomiting); CV effects (hypertension, chest pain, edema, palpitation); CNS effects (headache, dizziness); Other effects (increased susceptibility to infection, alopecia); Rarely, hepatic effects, dermatologic reactions (eg Stevens-Johnson syndrome [SJS], toxic epidermal necrolysis) Special Instructions Contraindicated in patients with significant hepatic impairment, bone marrow dysplasia Use with caution in patients with hematologic disorders, renal impairment TB screening prior to treatment Monitor CBC, LFT
Methotrexate	7.5 mg PO once weekly, adjust as needed or 2.5-7.6 mg PO 12 hourly x 3 doses weekly or 7.5 mg SC once weekly, adjust as needed Max dose: 20-25 mg PO/SC once weekly	Adverse Reactions CNS effects (dizziness, fever, seizure); GI effects (nausea/vomiting, loss of appetite, abdominal pain, diarrhea); Hematologic effects (anemia, leukopenia, thrombocytopenia); Other effects (alopecia, impairment of fertility, oligospermia); Potentially fatal: Hepatotoxicity, acute or chronic interstitial pneumonitis often associated with eosinophilia, severe dermatologic reactions (toxic epidermal necrolysis and SJS) Low-dose Methotrexate has been associated with development of malignant lymphomas Use may predispose patients to opportunistic infection Dosage exceeding 20 mg/week may cause a higher incidence and severity of adverse events Special Instructions Contraindicated in patients with alcoholic liver disease, pre-existing blood dyscrasias Use with caution in patients with peptic ulcer disease, ulcerative colitis, renal impairment May cause folic acid deficiency Some experts recommend concomitant administration of folic acid at 5 mg/week, except on the day of Methotrexate Monitor CBC with platelets, serum creatinine and LFT
Sulfasalazine	Initial dose: 500 mg PO 24 hourly x 1 week Increase dose by 500 mg weekly until max dose or give 1,000 mg PO 8-12 hourly Max dose: 3 g/day	Adverse Reactions CNS and behavioral effects (headache, dizziness, fever, insomnia, depression); Dermatologic effects (pruritus, urticaria, rashes, toxic epidermal necrolysis, SJS, drug rash with eosinophilia and systemic symptoms ); GI effects (nausea/vomiting, loss of appetite, abdominal pain); Hematologic effects (anemia, leukopenia, thrombocytopenia); Other effects (oligospermia, cyanosis, discoloration of body fluids, aseptic meningitis, ocular complications, alopecia) Special Instructions Contraindicated in patients with porphyria, GI or GU obstruction, blood dyscrasias Use with caution in patients with severe allergies or bronchial asthma, G6PD deficiency, hepatic and renal impairment May cause folic acid deficiency, consider giving folate supplement Monitor LFT and CBC during the first 3 months of treatment and periodic monitoring of kidney function is recommended
Targeted Synthetics
Baricitinib	4 mg PO 24 hourly May gradually reduce to 2 mg PO 24 hourly once sustained control of disease is achieved	Adverse Reactions GI effects (nausea, diverticulitis, GI perforation); Hematologic effects (lymphocytopenia, anemia, neutropenia, thrombocytosis); Other effects (lipid elevations, URTI, headache, malignancies) Increased risk of major CV events (sudden CV death, MI, stroke) Special Instructions Use with caution in patients with CV risk factors, known malignancy, chronic, active, or recurrent infections, abnormal blood cell levels, lipids and liver enzymes, high risk of thromboembolic events Screen for pulmonary TB and treat if positive prior to initiation of therapy Vaccination with live virus vaccines and use with DMARD or other JAK are not recommended
Filgotinib maleate	200 mg PO 24 hourly	Adverse Reactions Respiratory effects (URTI, pneumonia); Hematologic effects (lymphopenia, neutropenia); Other effects (dizziness, nausea, herpes zoster, sepsis, UTI, hypercholesterolemia, increased blood creatine phosphokinase) Special Instructions Should only be used if no suitable treatment alternatives are available in patients ≥65 years old, with history of atherosclerotic CV disease or other CV risk factors (eg current or chronic smokers), with malignancy risk factors Contraindicated in patients with hypersensitivity to Filgotinib maleate, active TB or active serious infections, pregnancy Use with caution in patients at increased risk for VTE or GI perforation Use of live vaccines during or immediately prior to treatment is not recommended
Tofacitinib	Immediate-release tab: 5 mg PO 12 hourly Extended-release tab: 11 mg PO 24 hourly	Adverse Reactions CV effects (decreased heart rate, prolonged PR interval, hypertension); Respiratory effects (URTI, cough, nasopharyngitis, pneumonia, TB, dyspnea, sinus congestion); GI effects (diarrhea, abdominal pain, dyspepsia, nausea/vomiting, gastritis); Dermatologic effects (cellulitis, erythema, rash, pruritus); Hematologic effects (neutropenia, anemia); Other effects (malignancy, thrombosis, UTI, herpes zoster infection, increased liver enzymes, lipid profile elevations, headache, fatigue) Special Instructions Use with caution in patients with active infections, increased risk for GI perforations, CV risk factors, lymphomas and other malignancies, severe hepatic impairment, high risk of thromboembolic events Monitor CBC and lipid profile
Upadacitinib	15 mg PO 24 hourly	Adverse Reactions Respiratory effects (URTI, cough, TB); GI effects (nausea, GI upset); Hematologic effects (neutropenia, anemia); Other effects (infections including opportunistic forms, lipid profile elevations, fever, weight gain, increased LFT, malignancy, thrombosis) Special Instructions Use with caution in patients with history of serious or opportunistic infections, risk factors for CV disorders, lymphoma and other malignancies, high risk of thromboembolic events Use in patients with severe hepatic impairment is not recommended Screen patients for TB, viral hepatitis and monitor for reactivation prior to initiation Perform periodic skin exam in patients at increased risk of skin cancer

Immunosuppressant

Drug

Dosage

Remarks

Tacrolimus

3 mg PO 24 hourly

Adverse Reactions

CNS effects (headache, tremor, paresthesia, hearing loss, visual disturbances, peripheral neuropathies, convulsions); CV effects (hypertension, cardiac arrest, heart failure, ventricular arrhythmias, palpitations, cardiomyopathies); GI effects (nausea, diarrhea, dyspepsia, constipation, GI hemorrhage and ulceration); Respiratory effects (dyspnea, parenchymal lung disorders, pleural effusions, cough, nasal congestion, pharyngitis, asthma); Dermatologic effects (acne, alopecia, skin rashes, pruritus); Musculoskeletal effects (muscle cramps, asthenia, arthralgia); Hematologic effects (pancytopenia, agranulocytosis, coagulation disorders); Other effects (renal impairment, hyperlipidemia, febrile disorders, edema, liver dysfunction)
Potentially fatal: Polyoma virus infections, GI perforation

Special Instructions

Use with caution in patients with renal impairment and hepatic impairment, patient with risk factors for QT prolongation

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) - Rectal

Drug	Available Strength	Dosage	Remarks
Diclofenac	12.5 mg suppository	75-150 mg 24 hourly in divided doses Max dose: 150 mg/day	Adverse Reactions May cause local effects (pruritus, rash, contact dermatitis, dry skin, pain, exfoliation, paresthesia, alopecia, edema, photosensitivity) Special Instructions Avoid use in patients with known hypersensitivity to the drug or any component of the formulation, including those in whom attacks of asthma, angioedema, urticaria, or rhinitis have been precipitated by Aspirin or any other NSAIDs Do not apply to non-intact or damaged skin (eg exudative dermatitis, eczema, infected lesions, burns or wounds)
Indometacin	100 mg suppository	1 suppository at bedtime or 1 suppository 12 hourly
Ketoprofen	100 mg suppository	1 suppostiory at night or 1 suppository 12 hourly May be supplemented with oral doses as needed Max dose: 200 mg/day

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) - Systemic

Acetic Acid Derivatives
Drug	Dosage	Remarks
Aceclofenac	100 mg PO 12 hourly Extended-release: 200 mg PO 24 hourly	Adverse Reactions GI effects (nausea, GI discomfort, diarrhea, peptic ulceration, GI bleeding); CNS effects (headache, vertigo, dizziness, nervousness, tinnitus, depression, drowsiness, insomnia); Hypersensitivity reactions (angioedema, bronchospasm, rashes, Stevens-Johnson syndrome occur rarely); Hematologic effects (anemia, thrombocytopenia, neutropenia); Other effects (hepatotoxicity, nephrotoxicity, hematuria, fluid retention, photosensitivity, pancreatitis) Coxibs have lesser GI effects Special Instructions May be given with food to decrease GI effects Avoid use in patients with active peptic ulceration, severe heart failure, history of allergy to Aspirin or other NSAIDs Coxibs should not be used in patients with moderate heart failure, ischemic heart disease, peripheral arterial disease, cerebrovascular disease Use with caution in patients with hypertension, infections, asthma or allergic disorders, hemorrhagic disorders, hepatic or renal impairment Coxibs should be used with caution in patients with left ventricular failure, edema, history of cardiac failure, with risk factors for developing heart disease
Acemetacin	60-180 mg/day PO in 1-3 divided doses Extended-release: 90 mg PO 24 hourly May be increased to 90 mg PO 12 hourly if necessary
Diclofenac (Diclofenac potassium, Diclofenac sodium)¹	75-150 mg/day PO in 2-3 divided doses Extended-release: 75 mg PO 12-24 hourly or 100 mg PO 24 hourly or 75-150 mg IM intragluteal injection 24 hourly x up to 2 days Max dose: 150 mg/day
Etodolac	Initial dose: 600-1,000 mg/day PO in divided doses Extended-release: 400-1,000 mg PO 24 hourly
Indometacin	25 mg PO 8-12 hourly May increase dose by 25 mg/day weekly up to 150-200 mg/day
Sulindac	150-200 mg PO 12 hourly Max dose: 400 mg/day
Butylpyrazolidine
Phenylbutazone	Up to 600 mg/day PO in divided doses	Adverse Reactions GI effects (nausea, GI discomfort, diarrhea, peptic ulceration, GI bleeding); CNS effects (headache, vertigo, dizziness, nervousness, tinnitus, depression, drowsiness, insomnia); Hypersensitivity reactions (angioedema, bronchospasm, rashes, Stevens-Johnson syndrome occur rarely); Hematologic effects (anemia, thrombocytopenia, neutropenia); Other effects (hepatotoxicity, nephrotoxicity, hematuria, fluid retention, photosensitivity, pancreatitis) Coxibs have lesser GI effects Special Instructions May be given with food to decrease GI effects Avoid use in patients with active peptic ulceration, severe heart failure, history of allergy to Aspirin or other NSAIDs Coxibs should not be used in patients with moderate heart failure, ischemic heart disease, peripheral arterial disease, cerebrovascular disease Use with caution in patients with hypertension, infections, asthma or allergic disorders, hemorrhagic disorders, hepatic or renal impairment Coxibs should be used with caution in patients with left ventricular failure, edema, history of cardiac failure, with risk factors for developing heart disease
Coxibs
Celecoxib	100-200 mg PO 12 hourly
Etoricoxib	60-90 mg PO 24 hourly
Fenamic Acid Derivative
Mefenamic acid	500 mg PO 8 hourly or 500 mg PO initially followed by 250 mg PO 6-8 hourly
Oxicam Derivatives
Meloxicam	15 mg PO 24 hourly Dose may be reduced to 7.5 mg/day
Piroxicam	10-20 mg PO 24 hourly
Tenoxicam	20 mg PO 24 hourly
Propionic Acid Derivatives
Dexibuprofen	600-900 mg PO 24 hourly in 2-3 divided doses Max dose: 1,200 mg/day	Adverse Reactions GI effects (nausea, GI discomfort, diarrhea, peptic ulceration, GI bleeding); CNS effects (headache, vertigo, dizziness, nervousness, tinnitus, depression, drowsiness, insomnia); Hypersensitivity reactions (angioedema, bronchospasm, rashes, SJS rarely occurs); Hematologic effects (anemia, thrombocytopenia, neutropenia); Other effects (hepatotoxicity, nephrotoxicity, hematuria, fluid retention, photosensitivity, pancreatitis) Special Instructions May be given with food to decrease GI effects Avoid use in patients with active peptic ulceration, severe heart failure, history of allergy to Aspirin or other NSAIDs Use with caution in patients with hypertension, infections, asthma or allergic disorders, hemorrhagic disorders, hepatic or renal impairment
Dexketoprofen	12.5 mg PO 4-6 hourly or 25 mg PO 8 hourly Max dose: 75 mg/day
Flurbiprofen	150-200 mg/day PO in divided 6-12 hourly Max dose: 300 mg/day
Ibuprofen²	200-400 mg PO 6-12 hourly or 800 mg PO 8-12 hourly Max dose: 2.4 g/day
Ketoprofen	50 mg PO 6 hourly or 75 mg PO 8 hourly Extended-release: 100-200 mg PO 24 hourly Max dose: 200 mg/day
Loxoprofen	60 mg PO 8 hourly Max dose: 180 mg/day
Naproxen³	500-550 mg PO as initial dose followed by 250-275 mg PO 6-12 hourly or 275 mg PO 12 hourly or 275 mg PO in the morning followed by 550 mg PO in the evening or 250-550 mg PO 6-12 hourly Delayed-release: 375-500 mg PO 12 hourly Extended-release: 750-1,000 mg PO 24 hourly Max dose: 1,500 mg/day for limited periods of up to 6 months
Salicylic Acid & Derivative
Diflunisal	500-1,000 mg/day PO divided 12 hourly Max dose: 1,500 mg/day
Other NSAID
Nabumetone	1,000 mg PO as single dose at bedtime Additional 500-1,000 mg may be given in the morning for severe or persistent symptoms Max dose: 2 g/day

¹Diclofenac Na and Lidocaine HCl injection combination is available. Please see the latest MIMS for specific formulations and prescribing information.
²Combination with Paracetamol is available. Please see the latest MIMS for specific formulations and prescribing information.
³Combinations with Esomeprazole and Omeprazole are available. Please see the latest MIMS for specific formulations and prescribing information.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) - Topical

Drug	Available Strength	Dosage	Remarks
Diclofenac	0.1%, 1% gel	Apply 2-4 g 6-12 hourly	Adverse Reactions May cause local effects (pruritus, rash, contact dermatitis, dry skin, pain, exfoliation, paresthesia, alopecia, edema, photosensitivity) Trolamine salicylate may cause mild irritation or erythema of the skin which are its desired effects Special Instructions Avoid use in patients with known hypersensitivity to the drug or any component of the formulation, including those in whom attacks of asthma, angioedema, urticaria, or rhinitis have been precipitated by Aspirin or any other NSAIDs Do not apply to non-intact or damaged skin (eg exudative dermatitis, eczema, infected lesions, burns or wounds) Discontinue Trolamine salicylate use if irritation worsens or persists for >7 days
	Extra 1% gel	Apply 2-4 g 6-8 hourly
	1.16% cream, 1.17% creamagel	Apply to affected area 6-12 hourly
	1% foam	Apply thinly to affected area 6-8 hourly
	1%, 30 mg patch	Apply 1 patch 12-24 hourly
	180 mg plaster	Apply 1-2 plasters 24 hourly
	1% spray	Spray on affected area 6-8 hourly
Etofenamate	5% gel	Apply 5-10 cm 6-8 hourly
Etofenamate	1% spray	Spray 7 times (18.4 mg) on affected area 4-8 hourly
Flurbiprofen	40 mg plaster	Apply 1 sheet 12 hourly
Ibuprofen	5%, 10% gel	Apply 50-125 mg (4-10 cm of 5% gel or 2-5 cm of 10% gel) 4-6 hourly
Indometacin	1% cream	Apply to affected area 5-8 hourly
	8 mg/mL spray	Spray on affected area 6-8 hourly Max dose: 25 mL/day
	10 mg/mL spray	Spray on affected area 6-8 hourly
Ketoprofen	2.5% gel	Apply 12-24 hourly
	20 mg (2%), 40 mg patch	Apply 24 hourly
	30 mg plaster	Apply 1 plaster 12 hourly
Piroxicam	0.5% gel	Rub 1-3 g (1.5-4.5 cm) 6-8 hourly
Piroxicam	48 mg patch	Apply 1 patch 48-72 hourly
Trolamine salicylate (Triethanolamine salicylate)	12% gel	Apply to affected area 6-8 hourly

Disclaimer

All dosage recommendations are for non-pregnant and non-breastfeeding women and non-elderly adults with normal renal and hepatic function unless otherwise stated.
Not all products are available or approved for above use in all countries.
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs.
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.

Rheumatoid Arthritis Drug Summary

Disease Summary

Disease Algorithm

Disease Background

Initial Assessment

Diagnostics

Differential Diagnosis

Management

Follow Up

Drug Summary

References