Rheumatoid Arthritis (Referral & Symptom Control)

7.5 mg orally once weekly, adjusted gradually to optimal response, maximum 20 mg weekly

Safety and effectiveness in children have not been established, other than in cancer chemotherapy.

Methotrexate 2.5mg Tablets SmPC section 4.2 Posology and method of administration (eMC product 4608)

Methotrexate is the anchor disease-modifying antirheumatic drug for rheumatoid arthritis, suppressing the immune-mediated synovial inflammation that drives joint damage; it is the established first-choice DMARD in modern rheumatoid arthritis management.

Rheumatoid Arthritis - disease-level clinical article (rheumatoid-arthritis-referral-clinical.txt)

Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen.

100 mg once daily for 3 days as a loading dose (which may be omitted to reduce adverse events), then 10-20 mg once daily depending on disease activity

Not recommended below 18 years - efficacy and safety in juvenile rheumatoid arthritis have not been established.

eMC SmPC, Leflunomide 20 mg film-coated tablets (Sandoz), sections 4.1 and 4.2

13 live products. The SmPC indication is active rheumatoid arthritis as a disease-modifying antirheumatic drug - an option for the patient who cannot take methotrexate.

7.5 to 10mg daily. For maintenance therapy the lowest effective dosage is used.

Specialist paediatric rheumatology supervision required

Prednisolone 5mg Tablets SmPC (https://www.medicines.org.uk/emc/product/4627/smpc)

Prednisolone is used as short-term bridge therapy alongside methotrexate, controlling joint inflammation and symptoms quickly while the slower-acting DMARD takes effect; it is tapered off once the DMARD is working, not continued as maintenance.

20 mg once daily. The maximum recommended daily dose is 20 mg. - Review benefit and tolerability within 14 days, as the SmPC requires; continue only with frequent review thereafter

Dosage recommendations and indications for use in children have not been established.

eMC SmPC, Piroxicam Capsules 20 mg (Strides Pharma UK), sections 4.1, 4.2 and 4.4

32 live products. The SmPC restricts piroxicam to symptomatic relief of osteoarthritis, rheumatoid arthritis and ankylosing spondylitis - and of those three, rheumatoid arthritis is the only condition in this dataset with a free slot. Marked as an adjunct because an NSAID relieves symptoms alongside a disease-modifying drug and never replaces one.

Initial 0.5 g daily for one week, increased by 0.5 g weekly until 0.5 g four times daily or 1 g three times daily (maximum 3 g daily)

The ENDF's paediatric sulfasalazine dosing is given for ulcerative colitis (children over 2 years of age); no paediatric rheumatoid arthritis figure is stated with it.

Egyptian National Drug Formulary - Gastrointestinal Tract 2025 (sulfasalazine monograph, rheumatoid arthritis)

The disease article names sulfasalazine as the alternative first-line DMARD when methotrexate is contraindicated or not tolerated - which includes pregnancy, where methotrexate cannot be used at all. The card carried methotrexate and leflunomide, both of which are contraindicated in pregnancy, with no alternative.

200 to 400 mg daily as a single daily dose or in 2 divided doses

The ENDF's paediatric dosing for hydroxychloroquine covers malaria chemoprophylaxis and treatment only. It gives no paediatric rheumatoid arthritis dose, so none is stated here.

Egyptian National Drug Formulary - Antimicrobial 2023 (Version 1.0), hydroxychloroquine monograph, Indications ("Rheumatoid arthritis") and Dosage Regimen, Adult Dosing, Rheumatoid arthritis

The disease article names hydroxychloroquine in the same sentence as the three nonbiologic DMARDs the card already carries (methotrexate, sulfasalazine, leflunomide) - it was the only one of the four missing. The ENDF names rheumatoid arthritis in the drug's own indications and gives the RA dose directly, so the indication limb needed no interpretation. DMARD therapy is started and monitored by the rheumatology service this card refers to; the row is here so the dose and the eye-screening requirement are visible in primary care, not so that it is initiated there.

Intravenous infusion, dosed by body weight, and never given alone. SmPC verbatim: "3 mg/kg given as an intravenous infusion followed by additional 3 mg/kg infusion doses at 2 and 6 weeks after the first infusion, then every 8 weeks thereafter." and "Remsima must be given concomitantly with methotrexate." Where response fades: "consideration may be given to increase the dose step-wise by approximately 1.5 mg/kg, up to a maximum of 7.5 mg/kg every 8 weeks. Alternatively, administration of 3 mg/kg as often as every 4 weeks may be considered." - Reviewed at 12 weeks. SmPC verbatim: "Available data suggest that the clinical response is usually achieved within 12 weeks of treatment." and "Continued therapy should be carefully reconsidered in patients who show no evidence of therapeutic benefit within the first 12 weeks of treatment or after dose adjustment."

Not a paediatric prescription in this disease. SmPC verbatim: "The safety and efficacy of infliximab in children and adolescents younger than 18 years for the indication of juvenile rheumatoid arthritis have not been established."

Remsima 100 mg powder for concentrate for solution for infusion (infliximab) SmPC sections 4.1, 4.2, 4.3 and 4.4 (eMC product 3709)

The disease article names it among the anti-TNF drugs, verbatim: "Anti-TNF-alpha inhibitors include etanercept, infliximab, adalimumab, golimumab, and certolizumab pegol." and places the class, verbatim: "The ACR does not recommend using TNF inhibitors until a nonbiologic DMARD has been tried." The SmPC's indication section names the disease, verbatim: Remsima "in combination with methotrexate, is indicated for the reduction of signs and symptoms as well as the improvement in physical function in: adult patients with active disease when the response to disease-modifying antirheumatic drugs (DMARDs), including methotrexate, has been inadequate." The card already carries the four non-biologic DMARDs the article names; the biologic step was not shown at all. Egypt registers one infliximab product, REMICADE 100 mg powder for intravenous infusion at roughly 5,900 EGP a vial, and a course is several vials per infusion at adult body weights.

100 mg to 200 mg twice daily

No paediatric dose for adult rheumatoid arthritis; the label's paediatric use is juvenile arthritis, a different condition.

Celecoxib DailyMed label, SetID 0ad14a4e-2f05-4ce7-93d1-1cb7e4d8f7d0, section 2.3 - verbatim: "For RA, the dosage is 100 mg to 200 mg twice daily."

The card's only NSAID is piroxicam, which the article ranks for efficacy but not for safety. Celecoxib is the article's pick where the stomach or bleeding is the limiting problem, so an elderly or ulcer-risk patient still has an option.