Conventional DMARDs (hydroxychloroquine, sulfasalazine, leflunomide)

Conventional DMARDs (hydroxychloroquine, sulfasalazine, leflunomide)

Drug monograph · NCLEX study reference
Trade names	Plaquenil, Azulfidine, Arava
Therapeutic class	Disease-modifying antirheumatic drugs
Pharmacologic class	Antimalarial (hydroxychloroquine), aminosalicylate (sulfasalazine), pyrimidine synthesis inhibitor (leflunomide)
Onset / peak / duration	Effect over weeks to months.
Half-life / level	Leflunomide very long (active metabolite); no routine level.
Routes	PO (oral)
High-alert (ISMP)	No
Black box warning	Yes (see Safety)
Antidote / reversal	Cholestyramine washout for leflunomide; supportive care.
Pregnancy / lactation	Leflunomide contraindicated; hydroxychloroquine often continued in lupus pregnancy.

Nursing pharmacology study reference (NCLEX-style monograph). Numeric values are standard teaching ranges for study and must be verified against current manufacturer labeling before clinical use. This is educational content, not prescribing guidance.

Conventional DMARDs (hydroxychloroquine, sulfasalazine, leflunomide) (brand names Plaquenil, Azulfidine, Arava) — Disease-modifying antirheumatic drugs; Antimalarial (hydroxychloroquine), aminosalicylate (sulfasalazine), pyrimidine synthesis inhibitor (leflunomide).

Identification

• Therapeutic class: Disease-modifying antirheumatic drugs.
• Pharmacologic class: Antimalarial (hydroxychloroquine), aminosalicylate (sulfasalazine), pyrimidine synthesis inhibitor (leflunomide).

Pharmacology

• Mechanism of action: Each reduces immune-mediated inflammation by a distinct mechanism.
• Onset / peak / duration: Effect over weeks to months.
• Half-life / therapeutic level: Leflunomide very long (active metabolite); no routine level.

Clinical use

• Indications: Rheumatoid arthritis, lupus (hydroxychloroquine), inflammatory bowel disease and rheumatoid arthritis (sulfasalazine).
• Usual dose, route, frequency: PO daily or divided.
• Maximum dose / adjustments: Hydroxychloroquine dosed by ideal body weight (retinal toxicity); leflunomide caution in hepatic disease.

Safety

• Contraindications: Hydroxychloroquine with retinal disease; sulfasalazine with sulfa allergy; leflunomide in pregnancy and significant hepatic disease.
• Black box warning: Leflunomide carries boxed warnings for hepatotoxicity and embryo-fetal toxicity (a drug elimination procedure with cholestyramine is needed because of its long half-life).
• Interactions: Hydroxychloroquine with QT-prolonging drugs and digoxin; sulfasalazine with folate (reduced); leflunomide with hepatotoxic drugs.
• Pregnancy / lactation: Leflunomide contraindicated; hydroxychloroquine often continued in lupus pregnancy.
• High-alert: No.

Adverse effects

• Common side effects: GI upset; sulfasalazine causes orange-yellow discoloration of urine and skin; hydroxychloroquine nausea.
• Serious effects to report: Hydroxychloroquine retinopathy (vision changes), sulfasalazine blood dyscrasias and hemolysis (G6PD), leflunomide hepatotoxicity.
• Antidote / reversal: Cholestyramine washout for leflunomide; supportive care.

Nursing process

• Assessment before administration: Baseline eye exam (hydroxychloroquine), CBC and LFTs, sulfa allergy, pregnancy status.
• Interventions during therapy: Schedule eye exams (hydroxychloroquine); monitor liver and counts.
• Monitor: Vision (hydroxychloroquine), CBC, LFTs.
• Evaluation / expected outcome: Reduced disease activity.

Patient teaching

• Patient teaching: Report vision changes (hydroxychloroquine); harmless orange-yellow color (sulfasalazine); reliable contraception (leflunomide).
• Notify provider if: Vision or color changes, fever or bruising, yellowing of skin.
• Administration tips: Take with food; keep eye exam schedule.