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Oxford University Hospitals NHS Foundation Trust
OxPARC

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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.