DMARDs
red flags in bloods
indicates urgent referral to rheum from primary care
Main risks:
- agranulocytosis
- impaired renal function
- impaired liver function
FBC
- White cell count lower than 3.5 x 109/L.
- Mean cell volume higher than 105 fL.
- Check B12, folate, and thyroid-stimulating hormone levels.
- If abnormal, treat; if normal, discuss with specialist team.
- Neutrophils lower than 1.6 x 109/L.
- Unexplained eosinophilia higher than 0.5 x 109/L
- Platelet count lower than 140 x 109/L.
U+E
- Creatinine has increased by more than 30% over 12 months and/or calculated glomerular filtration rate (GFR) is lower than 60 mL/min.
- Repeat in 1 week.
- If still more than 30% from baseline, withhold and discuss with specialist team.
Liver function tests
- Alanine aminotransferase (ALT) and/or aspartate transaminase (AST) higher than 100 U/L.
- Unexplained reduction in albumin lower than 30 g/L.
Others
- Blood pressure higher than 140/90mmHg.
- If on cislosporin, stop treatment and discuss with specialist team.
- If on other DMARDs, manage in accordance with hypertension guidelines.
- Urinary protein 2+ or more.
- Check mid-stream urine sample.
- If evidence of an infection, treat appropriately; if sterile and 2+ proteinuria or more persists on two consecutive measurements, withhold until discussed with specialist team.
routine monitoring
azathioprine, mycophenolate, sulfasalazine
| Monitoring | Frequency |
|---|---|
| FBC | - Every 2 weeks until dose is stable for 6 weeks, then monthly for 3 months. - Thereafter, at least every 12 weeks. - Monitor more frequently in people at higher risk of toxicity. - If dose is increased, monitor every 2 weeks until dose is stable for 6 weeks, then revert to previous schedule. |
| Renal function: creatinine/calculated GFR | |
| LFTs: ALT and/or AST and albumin |
ciclosporin, tacrolimus, leflunomide
| Monitoring | Frequency |
|---|---|
| FBC | - Every 2 weeks until dose is stable for 6 weeks, then monthly. - People who have been stable for 12 months can be considered for reduced monitoring frequency (every 3 months) on an individual basis. - Monitor more frequently in people at higher risk of toxicity. - If the dose is increased, monitor every 2 weeks until dose is stable for 6 weeks, then revert to previous schedule. |
| Renal function: creatinine/calculated GFR | |
| LFTs: ALT and/or AST and albumin | |
| Blood glucose | |
| Blood pressure |
Leflunomide - include weight
cyclophosphamide, penicillamine
| Monitoring | Frequency |
|---|---|
| FBC | - 10 days after each pulse therapy. - Blood tests repeated immediately prior to the next pulse. |
| LFTs: ALT and/or AST and albumin | |
| Urinalysis |
Penicillamine - include renal function
hydroxychloroquine
| Monitoring | Frequency |
|---|---|
| Renal function | - Annually in people aged over 70 years old and in those with pre-existing renal impairment, hypertension, and/or diabetes. |
| Eye assessment (ideally including optical coherence tomography) | - Annually for all people who have taken hydroxychloroquine for greater than 5 years. - Annual monitoring may be commenced before 5 years of treatment if additional risk factors for retinal toxicity exist, such as: - Concomitant tamoxifen therapy, impaired renal function (estimated glomerular filtration rate less than 60 mL/minute/1.73 m2) or - High-dose therapy (greater than 5 mg/kg/day of hydroxychloroquine). |
advice
- ↑ susceptibility to infection in 1st 6/12