Assessment and prescribing

DMARDs, corticosteroids and prescribing safety

Overview and approach

Rheumatology prescribing balances disease control against infection, organ toxicity and reproductive risks.

  • Aim to start DMARDs within 4 weeks of an RA diagnosis, allowing time for education and pre-treatment tests (2).
  • Classes: conventional synthetic (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide), then biologic or targeted synthetic DMARDs (TNF, IL-6, IL-17, IL-23 inhibitors, rituximab, abatacept, JAK inhibitors) (1)(5).
Assessment and clinical features

Verify indication, exact schedule, organ function, interactions, immunisation, pregnancy plans and monitoring responsibility.

  • Pre-treatment: screen for hepatitis B, hepatitis C, HIV and TB (TB and hepatitis B/C before any biologic), review vaccination including live vaccines, pregnancy plans, alcohol, previous malignancy; baseline FBC, renal function and LFT (2)(3)(5).
Differentials and investigations

Baseline/ongoing FBC, liver/renal testing and infection screening vary by drug; coordinate with the specialist/shared-care protocol.

  • Methotrexate: FBC, EUC/LFT and ESR/CRP monthly until the dose is stable for 3 months and nothing else has changed, then at least 3-monthly; at least 2-monthly if leflunomide is co-prescribed. Do not check methotrexate levels (3).
  • Leflunomide: regular CBC and LFT monitoring (5).
  • Sulfasalazine: CBC and LFT regularly (5).
  • Hydroxychloroquine: retinopathy screening follows a stratified Australian recommendation (March 2026) (1).
  • Biologics/JAK inhibitors: CBC and metabolic panel about every 3-4 months, lipids for JAK inhibitors (5).
Management and follow-up

Methotrexate is normally weekly in inflammatory disease. Avoid abrupt cessation of prolonged systemic steroids; tailor stress-dose advice and infection management.

  • Methotrexate: first-line csDMARD for RA. ONCE WEEKLY; agree the day and write it on the prescription. Folic acid reduces GI upset, raised LFTs and mouth ulcers (living guideline example: 5 mg once weekly the day after methotrexate). Oral first; consider subcutaneous if inadequate response or intolerance (1)(3)(4). Teratogenic (5).
  • Triple therapy (methotrexate + sulfasalazine + hydroxychloroquine) is conditionally suggested as initial therapy in RA (1).
  • Hydroxychloroquine in SLE: at or below 5 mg/kg/day of real body weight (6).
  • Leflunomide: teratogenic, needs a cholestyramine washout (5). Azathioprine: reduce the dose if allopurinol or febuxostat is co-prescribed (7)(8).
  • b/tsDMARDs: not PBS-subsidised for DMARD-naive RA; after an inadequate response to one TNFi, switch to another TNFi or a different mechanism (1).
  • Glucocorticoids in RA: short-term bridging at the lowest effective dose; not routinely long-term (over 6 months); short courses or intra-articular for flares. No routine extra stress-dose steroid for elective surgery in people on regular steroid; continue the usual dose including on the day of surgery. Do not routinely stop csDMARDs peri-operatively (1).
  • Bone protection: prednisolone 7.5 mg/day or more for 3 months or more is a recognised fracture risk; see the Osteoporosis page.
  • Do not routinely use opioids for pain in RA, axial SpA or psoriatic arthritis. In remission or low disease activity for 6 months or more, consider dose reduction rather than abrupt stopping (1).
Red flags and clinical pearls

Daily methotrexate errors can be fatal. Fever on immunosuppression, cytopenia, new dyspnoea or liver injury demands review.

  • Methotrexate toxicity: cytopenia, hepatotoxicity, pneumonitis, mouth ulcers (3)(5).
  • Class risks: TNFi (infection including TB); JAK inhibitors (cardiovascular events, thrombosis, cancer, zoster); rituximab (infection, reduced vaccine response); tocilizumab (bowel perforation in diverticular disease); abatacept (reduced vaccine response) (1).
  • ORAL Surveillance: tofacitinib did not show non-inferiority to TNFi for major cardiovascular events or cancer in people aged 50 or over with a cardiovascular risk factor (1).
  • Viva: triple therapy components; what to check before a biologic (TB, hepatitis B/C, vaccinations, pregnancy plans).
References
  1. Australian Living Guideline for Inflammatory Arthritis
  2. RA Clinical Care Standard 2024 (ARA)
  3. Metro North Health: Methotrexate, Rheumatology in Primary Care 2022
  4. Metro North Health: Shared care fact sheet, low-dose methotrexate (2019)
  5. StatPearls: Psoriatic arthritis (DMARD doses and monitoring)
  6. 2019 update of the EULAR recommendations for the management of SLE
  7. Australian and NZ gout recommendations, 3e Initiative
  8. Australian Prescriber: The management of gout
  9. RACGP osteoporosis resources (original Guideline check link)

Last updated from Sen’s notes on 9 October 2026.