Birmingham Community
Rheumatology Service
Guidelines on the use and monitoring of disease modyifying anti rheumatic drugs (DMARDS)
These guidelines have been produced to provide information about the use and monitoring to the most
commonly used DMARDS and are based on the British Society of Rheumatology Guidelines (June 2008). They
are not exhaustive and any questions or concerns about DMARDS should be referred to the Birmingham
Community Rheumatology Service
Telephone 0121 250 0376, Helpline 07595552782, Fax 0121 523 6163 e: rheum.lphc@nhs.net
Methotrexate
Azathioprine
Sulfasalazine
Leflunomide
Ciclosporin
Mycophenolate Mofetil
Hydroxychloroquine
Sodium Aurothiomalate
Summary of monitoring requirements
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Guidelines on the use and monitoring of Methotrexate
Methotrexate is an effective treatment for inflammatory joint disease and other auto-immune diseases. Toxicity can
occur, but if precautions are taken most patients tolerate oral methotrexate without serious problems. It may take 6 –
12 weeks before any benefit is seen. Patients will have received written and verbal information about the expected
benefits and potential side effects of methotrexate therapy. As the tablets are available in both 2.5mg and 10mg
strengths and are of similar appearance patients should be advised to check the tablet strength dispensed, patients
should also be aware of their weekly dose in milligrams. It is good practice to prescribe 2.5mg tablets to avoid
confusion. Methotrexate may also be given by sub-cutaneous injection (see separate protocol). Annual flu vaccination in
recommended. Where appropriate patients will be given a record card or booklet on which results can be documented
as per National Patient Safety Agency recommendations.
Typical dose regime: 10mg once weekly initially
Folic acid supplements:
increase by 5mg every 2 - 6 weeks to maximum dose of
Folic acid 5mg may be prescribed either once weekly or six days
weekly as per the prescribers preference. Should not to be taken
25mg weekly.
on same day as methotrexate.
Contra-indications:
Hepatic disease
Precautions:
Pregnancy or planned pregnancy – Methotrexate
Avoid or use with extreme caution in impaired renal function –
should ideally be stopped for 3 months prior to
monitor renal function
conception (for both men and women)
Respiratory disease
Breast feeding
Excess alcohol and smoking should be actively discouraged in
Moderate/severe renal impairment
patients taking Methotrexate
Avoid live vaccines
Use with caution in localized or systemic infection
Unexplained anaemia or cytopenia associated with
Unexplained anaemia or cytopenia associated with bone marrow
bone marrow failure
failure
Side effects :
Common – mouth ulcers, nausea, vomiting, diarrhoea, sore throat
Notable Drug Interactions:
Trimethoprim or Co-Trimoxazole (may precipitate bone Less common - Hair loss, rash, bone marrow suppression –
marrow suppression)
leucopenia, thrombocytopenia, anaemia. Pneumonitis, neurological
Phenytoin (antifolate effect increased)
symptoms, abnormal liver function
Tolbutamide (increase in serum concentration of
methotrexate)
Pre treatment assessment:
FBC; LFT; U&E’s; Chest x-ray (unless CXR done within last 6 months)
Pulmonary function tests may be indicated in patients with pre-existing pulmonary disease
Blood monitoring:
FBC/ WCC differential, U&E’s & LFT’s - every 2 weeks until dose and monitoring stable for 6 weeks
Then monthly until stable for one year
Then every 2 – 3 months based on clinical judgement and co-morbidity / dose
Withhold until discussed with rheumatology department if:
WBC <3.5 x 10 9/l
Severe oral ulceration or rash
Neutrophils <2.0 x 10 9/l
Significant deterioration in renal function
Platelets <150 x 10 9/l
New or increasing dyspnoea or cough
ALT > 3 x normal value or persistently > 2 x normal value
Abnormal bruising or sore throat ( withhold until FBC
Unexplained fall in Albumin (in absence of active disease)
result available)
If MCV >105fl serum folate and B12 should be measured
In addition to absolute values for haematological indices a rapid fall or consistent downward trend in any value should
prompt caution and extra vigilance. If in doubt please contact the rheumatology department.
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
1
Department of Rheumatology – Guidelines on the use and monitoring of Azathioprine
Azathioprine (Imuran) is an immunosuppressive medication used to treat rheumatoid arthritis and other auto-immune
disorders. It is also used as a steroid-sparing agent. Toxicity can occur, but if precautions are taken most patients tolerate
azathioprine without serious problems. It may take 6– 12 weeks before any benefit is seen. Annual flu vaccination is
recommended. Patients will have been given written and verbal information about the expected benefits and potential
side effects of azathioprine. Where appropriate patients will be given a record card or booklet on which blood test
results can be documented.
Typical dose regime:
Initially 25 – 50mg daily increasing over 4 – 6 weeks according to response blood results up to 2 – 3 mg/kg in divided doses.
Thiopurine methyl transferase (TPMT) enzyme result should be available prior to dose increase. If TPMT level low discuss with
discuss with rheumatologist prior to dose increase.
Contra-indications:
Precautions:
Hepatic disease
Use with caution in patients with impaired renal function and
TPMT deficiency
cardiac failure
Immunization with live vacines
Sun block and protective clothing should be encouraged to reduce
Relative contra-indications:
sunlight exposure
Breast feeding : limited evidence – it is suggested that
Use in caution in localized or systemic infection
risks be discussed with the patient and advice sought
Pregnancy or planned pregnancy: the risks of continuing therapy
from a specialist if necessary
versus discontinuation should be discussed with the patient: in
patients with systemic or autoimmune disease the risks to the
foetus from a flare of the disease is greater than the risk of
congenital abnormalities (no increase risk observed) or of
immunosupression in the foetus (very rare)
Side effects:
Common – Mouth ulcers, nausea, vomiting, diarrhoea,
sore throat
Less common – abnormal LFT’s, neutropenia,
leucopenia, hepatitis, hair loss
Notable Drug Interactions:
Allopurinol (reduced Azathioprine dose indicated)
Warfarin (inhibition of anticoagulant effects – warfarin dose may
need to be increased)
Phenytoin, Sodium valporate & Carbamazepime (azathioprine
reduces absorption)
ACE inhibitors (may precipitate anaemia - rare)
Aminosalicylates and sulfasalazine (may precipitate bone marrow
toxicity)
Trimethoprim or Co-Trimoxazole (haemotoxicity can occur)
Pre treatment assessment: FBC; LFT; U&E’s; TMPT assay
Blood monitoring:
FBC & LFT’s weekly for first 6 weeks then 2 weekly for further 6 weeks OR 2 weekly for first 12 weeks ( dependent
upon individual patient characteristics and prescriber preference), then monthly until dose stable for 6 months.
After 6 months if disease and dose stable reduce monitoring to every 2 - 3 months.
(If TPMT low levels monthly monitoring should continue)
If dose increase check FBC & LFT’s after 2 weeks then monthly for 6 months
U&E’s and creatinine 6 - 12 monthly (more frequently if deterioration in renal function suspected)
Withhold until discussed with rheumatology department if:
WBC <3.5 x 10 9/l
ALT > 3 x normal value or persistently > 2 x normal value
Neutrophils <2.0 x 10 9/l
Abnormal bruising or sore throat (withhold until FBC result available)
Platelets <150 x 10 9/l
Severe oral ulceration or rash
If MCV>105fl investigate further - check serum B12 and folate
In addition to absolute values for haematological indices a rapid fall or consistent downward trend in any value should
prompt caution and extra vigilance. If in doubt please contact the rheumatology department.
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
2
Department of Rheumatology – Guidelines on the use and monitoring of Sulfasalazine (Salazopyrin)
Sulfasalazine is used to treat rheumatoid arthritis, psoriatic arthritis and seronegative spondyloarthropathies. It has a
slow onset of action 6 – 12 weeks. Enteric-coated tablets should be prescribed as they are better tolerated. Monitoring is
required due to potential toxicity. It may be prescribed in combination with other disease modifying drugs or as a
monotherapy. Patients will have been given written and verbal information about the expected benefits and potential
side effects of Sulfasalazine. Where appropriate patients will be given a record card or booklet on which blood test
results can be documented.
Typical dose regime:
Either:
Week 1 - 500 mg daily
Week 2 - 500mg twice daily
Week 3 - 500mg am & 1gram pm
Week 4 - 1gm twice daily
OR
500mg twice daily for 2 weeks then increase to 1gm twice daily
The dose may be increased to 3 gm daily if no response
Contra-indications:
Sulphonamide allergy
Hepatic disease
Severe renal impairment
Side effects:
Common –Nausea, rash, headache, anorexia, discolouration of
urine, tears or soft contact lenses
Less common – abnormal LFT’s, neutropenia, leucopenia
(usually within first 6 months), hepatitis, sore throat, mouth
ulcers.
Oligospermia (reversible on discontinuation), photosensitivity
Pre treatment assessment: FBC; LFT; U&E’s;
Precautions:
Moderate renal impairment
May impair folate absorption
Patients should be asked about rashes or oral ulceration at
each visit.
Has proved safe in pregnancy but risk/benefit analysis should
be undertaken discussed with mother and the dose should
not exceed 2 gm daily.
Folic acid should be prescribed for those trying to conceive
and during pregnancy
Men wishing to father children should be advised that
spermatogenesis might be impaired causing infertility
Breast feeding acceptable as with pregnancy at maternal dose
of no more than 2 gm daily
Blood monitoring:
FBC & LFT’s 2 – 4 weekly monthly for first 3 months (dependent upon individual patient characteristics and clinician preference)
Then 3 monthly. If stable after 1-year tests can be 6 monthly for a year, then blood monitoring not strictly required.
U&E’s and creatinine 6 – 12 monthly (more frequently if deterioration in renal function suspected)
Withhold until discussed with rheumatology department if
WBC <3.5. X 10 9/l
Neutrophils <2.0 x 10 9/l
Platelets <150 x 10 9/l
ALT > 3 x normal value or persistently > 2 x normal value
Severe oral ulceration or rash
New or increasing dyspnoea or cough
Nausea/headaches – may need to reduce dose
Abnormal bruising or sore throat (withhold until FBC result
available)
Significant deterioration in renal function
If MCV >105fl investigate - check serum B12 and folate
In addition to absolute values for haematological indices a rapid fall or consistent downward trend in any value should
prompt caution and extra vigilance. If in doubt please contact the rheumatology department.
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
3
Guidelines on the use and monitoring of Leflunomide (Arava)
Leflunomide (Arava) is indicated for the treatment of rheumatoid and psoriatic arthritis. It has a slightly more rapid onset
of action than other disease modifying drugs and therapeutic effect may be seen within 4 – 6 weeks. Monitoring is
required due to potential toxicity. It may be used in conjunction with other disease modifying drugs or as a
monotherapy. Annual flu vaccination is recommended. Patients will have been given written and verbal information
about the expected benefits and potential side effects of Leflunomide. Where appropriate patients will be given a record
card or booklet on which blood test results can be documented.
Typical dose regime: 10 or 20mg once daily. If patients experience minor side effects at 20mg daily, the dose can be
reduced to 10mg daily.
Contra-indications:
Hepatic disease/ impaired liver function
Pregnancy or planned pregnancy/ breast feeding
Severe immunodeficiency
Moderate or severe renal impairment
Severe hypoproteinaemia (nephrotic syndrome)
Severe infection
Impaired bone marrow function
Live vaccines should be avoided
Side effects:
Common – Mouth ulcers, nausea, vomiting, diarrhoea, sore
throat, alopecia, hypertension, skin rash
Less common – abnormal LFT’s, hepatitis, bone marrow
suppression - neutropenia, leucopenia thrombocytopenia,
anaemia, pulmonary complications, weight loss
Precautions:
Patients should be advised about the use of contraception
if applicable, whilst on leflunomide, and for two years after
treatment.
Localized or systemic infection
Notable drug interactions:
Phenytoin
Tolbutamide
Warfarin
As Leflunomide has a long half-life washout procedure may be considered if side effects or if an alternative disease
modifying drug to be commenced: Cholestyramine 8g TDS for 11 days or Activated charcoal 50g QDS for 11 days. For
planned pregnancy the pharmaceutical company should be contacted for advice
Pre treatment assessment: FBC; LFT’s; U&E’s; Blood pressure; Weight
Blood monitoring:
FBC & LFT’s every month for 6 months
Then every 2 months
Monthly blood pressure .
Withhold until discussed with rheumatology department if:
WBC <3.5 x 10 9/l
ALAT > 3 x normal value or persistently > 2 x normal value
Neutrophils <2.0 x 10 9/l
Severe oral ulceration or rash
Platelets <150 x 10 9/l
Abnormal bruising or sore throat (withhold until FBC result available)
Shortness of breath
In addition to absolute values for haematological indices a rapid fall or consistent downward trend in any value should
prompt caution and extra vigilance. If in doubt please contact the rheumatology department.
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
4
Guidelines on the use and monitoring of Ciclosporin ( Neoral)
Ciclosporin (Neoral) is an immunosuppressive agent, indicated for the treatment of rheumatoid arthritis, psoriatic
arthritis and SLE. It can be used as a monotherapy or in combination with methotrexate. It can take up to 12 weeks to
take effect. Monitoring is required due to potential toxicity. Patients will have been given written and verbal information
about the expected benefits and potential side effects of Ciclosporin. Where appropriate patients will have a record card
or booklet on which results can be recorded.
Typical dose regime: 2.5mg/kg/day in two divided doses, increasing if indicated after four weeks by 25mg increments to
maximum dose of 4mg/kg/day
Contra-indications:
Precautions:
Uncontrolled hypertension
Grapefruit juice or grapefruit should not be ingested for one
Renal impairment
hour prior to Ciclosporin as it may decrease absorption.
Avoid live vaccines
PUVA therapy in psoriatic arthritis (discuss with dermatology
Severe hepatic disease
dept.)
Severe hyperkalemia
Suspected systemic infection
Side effects: (Often dose dependent and responsive to dose
reduction)
Relative contra-indications
Common – Hypertension, impaired renal function,
Past or current malignancy
hypertrichosis, headaches, tremor, fatigue, gingival
Pregnancy/planned pregnancy or breast feeding
hypertrophy, gastrointestinal disturbances (abdominal pain,
(there is experience in the transplant literature but
nausea, anorexia, diarrhoea, vomiting), burning sensation of
risk/benefit ratio needs careful evaluation in individual
hands and feet.
cases by an expert in this field)
Less common –
Hepatic dysfunction, pancreatitis, weight increase, oedema,
neuropathy, cramps, muscle weakness, paresthesia, confusion,
Notable drug interactions
hyperuricaemia, hyperkalaemia, leucopenia, reversible
There are multiple drug interactions – detailed below
dysmenorrhoea or amenorrhoea
Pre treatment assessment:
U&E’s; Creatinine X 2 normal prior to commencement 2 weeks apart (mean creatinine value required), FBC, fasting lipids, LFT’s
blood pressure x 2 normal 2 weeks apart
Monitoring:
U & E; s and serum creatinine every 2 weeks until dose and trend stable for 3 months then monthly.
FBC, LFT’s monthly until dose and trend stable for 3 months, then 3 monthly.
Fasting lipids 6 – 12 monthly
Blood pressure at each visit
Withhold until discussed with rheumatology department if:
Platelets <150 x 10 9/l
Abnormal bruising
Potassium increase above normal value
ALT or alkaline phosphates > 3 x normal value or persistently
> 2 x normal value
Significant rise in fasting lipds
Creatinine rise >30% from baseline ( dose adjustment may be required)
Uncontrolled hypertension :If increase in mean diastolic blood pressure >95mmHg – 110mmHg on 2 consecutive occasions
commence anti-hypertensive treatment with medication that does not interfere with pharmacokinetics
In addition to absolute values for haematological indices a rapid fall or consistent downward trend in any value should
prompt caution and extra vigilance. If in doubt please contact the rheumatology department.
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
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Ciclosporin cont………
DRUG INTERACTIONS WITH CICLOSPORIN
NEPHROTOXIC AGENTS:
NSAID’s
Aminoglycosides
Amphotericin B
Ciprofloxaxin
Trimethoprim
ACE inhibitors
DRUGS WHICH INCREASE CYCLOSPORIN LEVELS
Antibiotics: Erythromycin, Clarithromycin, Doxycycline,
Antifungals:Fluconazole, Ketoconazole, Itraconazloe,
Calcium channel blockers: Nicardipine, Amlodipine,
Diltiazem, Verapamil
Others: Oral contraceptives, Colchicine, H2 antagonists
EFFECTS OF CYCLOSPORIN ON DRUG METABOLISM
HMG CoA Reductase inhibitors:
Simvastatin, Lovastatin, Atrovastatin
Digoxin
Prednisolone
Nifedipine
Colchicine
Potassium sparing diuretics/potassium supplements
Avoid or reduce dose when practically possible.
Monitor renal function
DRUGS WHICH DECREASE CYCLOSPORIN LEVELS
Anti epileptics: Phenytoin, Carbamazepine, Primdione,
Antibiotics: Rifampicin, Trimethoprim,
Sulphonamides
May increase levels and risk of rhabdomyolysis. (Does not
interact with Pravastatin and Fluvastatin
May increase levels
Reduces clearance
Increase rates of gingival hyperplasia noted
Reports of muscular toxicity
Avoid if risk of hyperkalaeima.
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
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Guidelines on the use and monitoring of Mycophenolate Mofetil (MMF / Cellcept)
Mycophenolate Mofetil (MMF) is an immunosuppressant drug originally used as an anti-rejection agent following organ
transplantation. MMF is a potent reversible selective inhibitor of purine synthesis, which has been shown to inhibit T cell
proliferation and antibody production by B cells. It is used in SLE, Systemic Sclerosis, Vasculitis and other autoimmune
disorders. Patients will be given written and verbal information about the medication and potential side effects and
where appropriate provided with a record card or booklet on which blood tests can be recorded. Annual flu vaccination
is recommended.
Typical dose regime: 500mg twice daily for two weeks, then increase if tolerated to 1gm twice daily. Sometimes 2 grams daily
(especially Afro-Caribbeans)
Contra-indications:
Precautions:
Severe Hepatic disease
Localized or systemic infection
Severe renal impairment
Suspected lymphoproliferative disorder or unexplained
Pregnancy or planned pregnancy
thrombocytopenia, leucopenia or anaemia
Breast feeding
Avoid live vaccines
Side effects:
Common – nausea, vomiting, diarrhoea, abdominal
pain, leucopenia, increased risk of infection, abnormal
bruising,
Notable Drug interactions:
Avoid co administration of antacids with aluminium hydroxide or
magnesium, and cholestyramine as absorption may be reduced
Acyclovir levels of MMF or acyclovir may be increased
Probenecid (increase in plasma concentration of MMF)
Less common- Weight loss, Tremors, flushing,
lymphadenopathy, rash, visual disturbances, myalgia,
dysuria
Pre treatment assessment: FBC; LFT; U&E’s; Chest x-ray
Blood monitoring:
FBC / WCC differential weekly until dose stable for 4 weeks
Then 2 weekly for 2 months
Then monthly for as long as patient takes drug
Withhold until discussed with rheumatology department if:
WBC <3.5 x 10 9/l
Severe oral ulceration or rash
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Neutrophils <2.0 x 10 /l
Significant deterioration in renal function
Platelets <150 x 10 9/l
Gastro intestinal disturbances – withhold until settles then re-introduce at lower dose
Abnormal bruising or sore throat (withhold until FBC result available)
In addition to absolute values for haematological indices a rapid fall or consistent downward trend in any value
should prompt caution and extra vigilance. If in doubt please contact the rheumatology department.
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
7
Guidelines on the use and monitoring of
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine (Plaquenil) is used for treatment of rheumatoid arthritis, SLE and discoid lupus. It is make take 12-14
weeks before benefit is noted. Blood monitoring is not required but monitoring of visual acuity should be carried out.
Patients will have been given written and verbal information about the expected benefits and potential side effects of
hydroxychloroquine.
Typical dose regime: 200mg – 400mg daily. Dose should not exceed 6.5mg/kg/day
Contra-indications:
Severe to moderate renal impairment - reduced dose may
be indicated
Pre-existing maculopathy
Precautions:
May be continued during pregnancy/breast feeding Avoid
antacids within 4 hrs of dose
Epilepsy – threshold for convulsions may be reduced
May exacerbate psoriasis
Side effects:
Common - Rash, nausea, abdominal pain, headache
Notable drug interactions:
Digoxin - (plasma concentration of digoxin may be
increased)
Ciclosporin (plasma concentration of ciclosporin may be
increased)
Amiodorone, moxifloxacin, quinine and mefloquine should
not be used concomitantly
Less common –
Pigmentary skin changes, muscle weakness, Retinopathy
Pre treatment assessment: FBC; LFT; U&E’s
*Ask about visual impairment (which is not corrected by glasses)
Record near visual acuity of each eye (with glasses where appropriate) using reading chart and assess fundi.
If visual impairment is present an assessment by an optometrist is advised.
If there is any baseline abnormality in the fundi, refer to an ophthalmologist
Monitoring:
No blood monitoring required
Visual Acuity:
*Yearly monitoring of visual acuity using the reading chart and enquiring about visual symptoms is
recommended –if deterioration from baseline consider referral to optometrist.
*Ocular Toxicity and Hydroxychloroquine: Guidelines for Screening 2004
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
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Guidelines on the use and monitoring of
Intra Muscular Gold Inections ( Myocrisin, Sodium Aurothiomalate)
Intramuscular gold is used in treatment of rheumatoid arthritis. The benefit may not be noted for 3 – 6 months.
Monitoring is required due to potential toxicity even with long-term use. Patients will have been given written and verbal
information explaining the expected benefits and potential side effects of gold injections.
Typical dose regime:
Deep intramuscular to thigh or buttock. Initially a 10mg test dose is given (usually in clinic) 30 minute observation
afterwards
Followed by weekly injection of 50mg until significant response or until 1000mg given (if no response after total dose
1000mg given treatment should be stopped).
Dose interval progressively increased aiming for maintenance dose of 50mg monthly
Contra-indications:
Severe to moderate renal impairment,
Hepatic disease
Breast feeding
History of blood dyscrasia or exfoliative dermatitis
Significant pulmonary fibrosis
Systemic Lupus erythematosus
Porphyria
Avoid live vaccinations
Precautions:
Mild renal or hepatic impairment
Urticaria or eczema
Usually contraception during use is advised but may be
used at low dose or monthly in pregnancy after discussion
of risks/benefits
Side effects:
Common - Rash, loss of taste or metallic taste,
mouth ulcers, nausea, diarrhoea, dizziness, facial flushing
Less common –
Bone marrow suppression – leucopenia, thrombocytopenia,
proteinuria, pneumonitis
Pre treatment assessment: U&E’s; Creatinine; FBC;; LFT’s Urinalysis
Monitoring:
FBC and urinalysis at time of each injection. (The results of the FBC must be available before the next injection (i.e. it is
permissible to work one FBC in arrears)
Ask about oral ulceration or rash at each visit
Withhold until discussed with rheumatology department if
WBC <3.5. x 10 9/l
>1+ haematuria on> 1 occasion
Neutrophils <2.0 x 10 9/l
Severe oral ulceration or rash
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latelets <150 x 10 /l
Abnormal bruising or sore throat (withhold until FBC result available)
Eosinophillia >0.5 x 10 9/l
>2+ proteinuria on > 1 occasion (MSU to exclude infection)
In addition to absolute values for haematological indices a rapid fall or consistent downward trend in any value should
prompt caution and extra vigilance. If in doubt please contact the rheumatology department.
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
9
SUMMARY OF UPDATED DMARD MONITORING GUIDELINES ( Sept 2008)
METHOTREXATE:
FBC/ WCC differential, U&E’s & LFT’s - every 2 weeks until dose and monitoring stable for 6 weeks
Then monthly until stable for one year
Then every 2 – 3 months based on clinical judgement and co-morbidity / dose
AZATHIOPRINE:
FBC & LFT’s weekly for the first 6 weeks then 2 weekly for further 6 weeks OR 2 weekly for first 12 weeks
(dependent upon individual patient characteristics and clinician preference) then monthly until dose stable for
6 months.
After 6 months if disease and dose stable reduce monitoring to every 2 - 3 months.
(If TPMT low levels monthly monitoring should continue)
If dose increase check FBC & LFT’s after 2 weeks then monthly for 6 months
U&E’s and creatinine 6 - 12 monthly (more frequently if deterioration in renal function suspected)
SULFASALAZINE:
FBC & LFT’s 2 – 4 weekly monthly for first 3 months (dependent upon individual patient characteristics and
clinician preference).
Then 3 monthly
If stable after 1-year tests can be 6 monthly for a year, then blood monitoring not strictly required.
U&E’s and creatinine 6 – 12 monthly (more frequently if deterioration in renal function suspected
LEFLUNOMIDE:
FBC & LFT’s every month for 6 months
Then every 2 months
Monthly blood pressure
CICLOSPORIN:
U & E; s and serum creatinine every 2 weeks until dose and trend stable for 3 months then monthly.
FBC, LFT’s every 2 weeks until dose and trend stable for 3 months then 3 monthly
Fasting lipids 6 – 12 monthly
Blood pressure at each visit
MYCOPHENOLATE MOFETIL:
FBC / WCC differential weekly until dose stable for 4 weeks
Then 2 weekly for 2 months
Then monthly for as long as patient takes drug
HYDROXYCHLOROQUINE:
No blood monitoring required
Visual Acuity:
*Yearly monitoring of visual acuity using the reading chart and enquiring about visual symptoms is recommended
– if deterioration from baseline consider referral to optometrist.
SODIUM AUROTHIOMALATE:
FBC and urinalysis at time of each injection. (The results of the FBC must be available before the next injection
(i.e. it is permissible to work one FBC in arrears)
Ask about oral ulceration or rash at each visit
Guidelines based on British Society of Rheumatology Recommendations (June 2008)
10