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Drug monitoring guidelines

Monitoring schedule

This Shared Care protocol provides a monitoring schedule for routine disease modifying anti- rheumatic drugs (DMARDs), which may be used individually or in combination.

Variations in monitoring requirements may occur and this should be read in conjunction with:

Medication specific information provided by the rheumatology unit
Manufacturers data sheet

If in doubt, contact us.

DMARD	History, examination	Laboratory tests
Adalimumab	Mouth ulcers Fever Chills Bruising Pallor Signs of other autoimmunity	FBC, LFTs, U&Es - Monthly for 3 months; then 3 monthly dsDNA - Yearly
Anakinra	Respiratory signs and symptoms	FBC - Monthly for 3 months; then 3-monthly
Azathioprine	Fever Bruising Pallor	FBC, U&E's, LFTs - Monthly bloods for 6-12 months, if stable extend to 6-8 weekly
Ciclosporin	Peripheral oedema Mouth ulcer Rash Blood pressure	FBC, U&Es, creatinine - Fortnightly for 6 weeks; then 1-2 monthly LFTs - Monthly especially if concomitant NSAIDs Lipids - Every 6 months.
Cyclophosphamide (IV)	Fever Bruising Pallor	FBC, U&Es, LFTs, urine dipstick - 10 days after last dose and 2 days before next
Etanercept	Mouth ulcers Fever Chills Bruising Pallor Signs of other autoimmunity	FBC, LFTs, U&Es - 1-3 Monthly dsDNA - Yearly
Hydroxychloroquine	Annual Visual acuity	-
Leflunomide	Mouth ulcer Rash Blood pressure Weight loss	FBC, U&E's, LFTs - 2 weekly for 2 months, monthly for 6 months, then if stable extend to 2 monthly
Infliximab	Mouth ulcers Fever Chills Bruising Pallor Signs of other autoimmunity	FBC, LFTs, U&Es - Before each infusion dsDNA - Yearly
Methotrexate	Fever Bruising Pallor Mouth ulcer Respiratory signs and symptoms	FBC, U&Es, LFTs - 2 weekly for 1 months, monthly for 6 months, then if stable extend to 2-3 monthly
Mycophenolate	Fever Bruising Pallor Mouth ulcer	FBC - Weekly for 4 weeks; then monthly LFTs U&Es ESR and CRP - Monthly
Sulfasalazine	Mouth ulcers Fever Chills Bruising Pallor	FBC, LFTs - Fortnightly for 2 months; then 3 monthly

These guidelines are based on:

National Guidelines for the monitoring of second line drugs. British Society for Rheumatology. 2007.
Shared Care Agreement 2007 for Rheumatology Depts in Oxford and Heatherwood & Wexham Park
NHS-prodigy guidelines - Monitoring people on disease-modifying drugs (DMARDs)
British Society for Paediatric and Adolescent Guidelines

Drug monitoring actions

General guidelines

These guidelines apply to DMARD therapy including azathioprine, methotrexate, sulphasalazine, mycophenalate, cyclosporin, and biologic treatment (anti-TNF and anakinra).

Please contact us as described below or if you have any concerns.

We advise withholding medication and contacting one of the OxPARC medical team if there is:

A rapid fall or a consistent downward trend in any value and prompt extra vigilance.
Abnormal bruising or sore throat – withhold until FBC result available
Unusual rash or oral ulceration that may be attributed to medication
Unexpected fall in albumin
New or increasing dyspnoea or cough in absence of asthma or respiratory infection

Test	Result	Action
Hb	<100	Withhold for 2 weeks (doses) and recheck 3-4 days before 3rd dose. If returns to normal, re-start at usual dose Contact us to let us know of a change or persistent problem
Neutrophil count	< 1.5
Lymphocytes	<0.5
Platelet count	< 150
WCC	<3
AST or ALT	> 120
Creatinine	50% above normal

Drug Specific Guidelines

Drug	Withhold if
Cyclosporin	Potassium rises to above 6.5 BP rises to systolic BP > 95% for age/height
Anti-TNF therapy	Major surgery Infection requiring hospitalisation or if unusual Referral for medical assessment of abnormal symptom Presence of a positive dsDNA titre

If medication is withheld please contact us.

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