NSAIDs: indicated for arthralgia/arthritis, myalgia, and mild serositis. Be aware of gastrointestinal adverse effects such as gastritis and peptic ulcer disease (use additional PPI protection when needed) as well as renal impairment. PPI co-therapy is needed in older patients and in those with a history of peptic ulcer disease. Common NSAIDs include: meloxicam 15 mg (ampoule), meloxicam 15 mg (tablet), meloxicam 7.5 mg, piroxicam betacyclodextrin 20 mg (tablet, ampoule), diclofenac 75 mg (ampoule), diclofenac 50/75/100 mg (tablet), diclofenac 50 mg, diclofenac 1% 20 mg (gel), celecoxib 100/200 mg, etoricoxib 60/90/120 mg (tablet), naproxen 500/250/375 mg (tablet), indomethacin 50/25/75/100 mg, loxoprofen, ibuprofen 400 mg, tenoxicam 20 mg, etc. NSAIDcontraindications and adverse effects must always be considered. PPIs used for gastrointestinal protection include omeprazole 20 mg, lansoprazole 30 mg, pantoprazole 20 - 40 mg, esomeprazole 20 mg, esomeprazole 40 mg, and rabeprazole 20 mg. Analgesics: paracetamol 500/650 mg; paracetamol 325 mg + tramadol 37.5 mg; paracetamol + codeine phosphate; paracetamol 325 mg + ibuprofen 200 mg. Corticosteroids: - Intra-articular corticosteroid injection is indicated when one or two joints are involved and do not respond to systemic treatment. Injections are given 7 - 10 days apart, no more than 2 injections inone treatment course; courses should be separated by 3 - 6 months, with no more than 3 courses per year. Strict aseptic technique is mandatory. - Common local corticosteroid preparations are: • Methylprednisolone acetate (1 mL ampoule - 40 mg), long acting. Dose per injection: 10 - 20 mg (0.25 - 0.5 mL), depending on the site. • Betamethasone dipropionate (1 mL ampoule - 4 mg), long acting. Dose per injection: 1 - 2 mg (0.25 - 0.5 mL), depending on the site. • Triamcinolone acetonide (2 mL ampoule - 80 mg), also long acting. Dose per injection: 20 - 40 mg (0.5 - 1 mL), depending on the site. - Systemic corticosteroids are used in combination with immunosuppressive therapy. The dose is 0.5 - 1 mg/kg prednisone or equivalent. Taper gradually after 2 - 6 weeks and discontinue after 3 - 6 months once the disease-modifying treatment has taken effect. Adverse effects include adrenal insufficiency, osteoporosis, myopathy, neurologic toxicity, and opportunistic infection. Common formulations include prednisone 5 mg and methylprednisolone tablets (4 mg/16 mg). Explain it in simple words

6.3.2.1. Conventional syntheticDMARDs (csDMARDs) Methotrexate is the first-line drug in the treatment of rheumatoid arthritis. It is metabolized in the liver and excreted by the kidneys. How to use: 1 tablet = 2.5 mg. The usual starting dose is 10 - 15 mg/week, taken as a single weekly oral dose. The dose is then increased by 2.5 mg every 2 - 4 weeks. Dose escalation is based on treatment response, because the effect of methotrexate is slow and usually appears after 4 - 8 weeks. If after 3 - 6 months the dose has been increased to >= 20 mg/week and the patient still does not respond, methotrexate can be combined with other DMARDs or biologic agents. The maximum dose is 25 mg/week (10 tablets). Doses above 25 mg may lead to methotrexate toxicity. To reduce methotrexate adverse effects, use folic acid: 1 mg/day or 15 - 20 mg/week. Because dose escalation is slow and adverse effects are relatively common, regular monitoring is required. Before treatment, obtain CBC, liver enzymes, and serum creatinine. Repeat monthly for 6 months, then every 2 months. - If liver enzymes rise to < 2 times the normal value, repeat testing after 2 weeks. - If liver enzymes rise to > 2 times but < 3 times the normal value, reduce the methotrexate doseand repeat testing after 2 weeks. - If liver enzymes rise to > 3 times normal or remain elevated persistently, discontinue the drug. Common adverse effects: gastrointestinal upset (nausea, vomiting, anorexia, diarrhea), granulocytopenia, and hepatitis (common). Rare: cirrhosis. In a small number of cases: methotrexate-induced interstitial pneumonitis (clinically dyspnea, cough, fever, and interstitial infiltrates on chest radiograph). Infection must be excluded; if not due to infection, methotrexate should be stopped. Use methotrexate cautiously in the following situations: - Pregnancy: teratogenic. - Predisposition to granulocytopenia. - Hepatitis or alcohol dependence. - Active infection: the infection must be fully treated before methotrexate is started. - Impaired renalfunction. - Methotrexate allergy. - While taking methotrexate, hepatitis viral vaccination should not be administered. Other DMARDs such as hydroxychloroquine and leflunomide are less often used alone and are commonly combined with methotrexate: - Hydroxychloroquine (HCQ): 200 - 400 mg/day. Reduce the dose in hepatic or renal impairment; monitor for cardiovascular and ocular complications. - Leflunomide: 100 mg/day for 3 days, followed by 20 mg/day. An important adverse effect is hepatotoxicity; discontinue if ALT rises > 3 times normal. Other adverse effects include skin reactions, gastrointestinal effects, and anemia. - Sulfasalazine (SSZ): start at 1 g/day, increase weekly to 2 g/day, maximum 3 g/day. Adverse effects involve the skin, gastrointestinal tract, liver, and leukocyte/platelet suppression.