Bones and Joints
Table 1: Recommended Investigations for some commonly used DMARDs1,2,3,4,5,6
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Full colour PDF of the pages as they appeared in ‘best practice’.
Printer friendly PDF.The following recommendations are based on international guidelines and represent the most rigorous monitoring regimen. However local guidelines vary, so it is important to follow the advice of the treating rheumatologist, especially in regards to frequency of testing.
Methotrexate | Sulfasalazine | Hydroxychloroquine | Leflunomide | Azathioprine | Cyclosporin | Sodium aurothiomalate, injectable gold
| Methotrexate | |||
| Monitoring | Frequency | What to look for | What to do |
| Complete blood count (CBC) | Baseline Then every 2 weeks until dose of methotrexate and monitoring has been stable for 6 weeks Thereafter every 4 weeks |
WBC <3.5 x 109/L Neutrophils <2.0 x 109/L Platelets <150 x 109/L |
Discuss with specialist team immediately. |
| MCV > 105 fL | Check vitamin B12, folate and TSH. If abnormal, treat any underlying abnormality. | ||
| Liver function tests (LFTs) | Baseline Then every 2 weeks until dose of methotrexate and monitoring has been stable for 6 weeks Thereafter every 4 weeks |
AST, ALT > twice the upper limit of reference range. | Withhold until discussed with specialist team. Other factors to consider:
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| Unexplained decrease in albumin (in absence of active disease) | Withhold until discussed with specialist team | ||
| Serum creatinine | Baseline Then every 2 weeks until dose of methotrexate and monitoring has been stable for 6 weeks Thereafter every 4 weeks |
Significant deterioration in renal function | Reduce dose |
| Rash or oral ulceration | Withhold until discussed with specialist team. Folinic acid mouth wash may help with mucositis. | ||
| Nausea and vomiting, diarrhoea | Giving methotrexate by subcutaneous injection is often a good way of avoiding nausea. | ||
| New or increasing dyspnoea or dry cough (pneumonitis) | Some teams perform baseline chest x-ray and respiratory function tests | Withhold and discuss URGENTLY with specialist team. Arrange chest x-ray and respiratory function tests | |
| Severe sore throat, abnormal bruising | Immediate CBC and withhold until results available. Discuss any unusual results with specialist team | ||
| Sulfasalazine | |||
| Monitoring | Frequency | What to look for | What to do |
| Complete blood count (CBC) | Baseline Then every 2 weeks for the first 2 months Then monthly for next 3 months Thereafter 3-monthly |
WBC <3.5 x 109/L Neutrophils <2.0 x 109/L Platelets <150 x 109/L |
Discuss with specialist team immediately. |
| MCV > 105 fL | Check vitamin B12, folate and TSH. Treat any underlying abnormality | ||
| Liver function tests (LFTs) | Baseline Then every 2 weeks for the first 2 months Then monthly for next 3 months Thereafter 3-monthly |
AST, ALT > twice the upper limit of reference range | Withhold until discussed with specialist team. Consider the use of alcohol, NSAIDs or new alternative medicines |
| Nausea/dizziness/headache | If possible, continue treatment. May have to reduce dose or stop if symptoms are severe. Discuss with specialist team | ||
| Abnormal bruising or sore throat | Check CBC immediately and withhold until results are available. Discuss with specialist team if necessary | ||
| Unexplained acute widespread rash | Withhold and seek URGENT specialist (preferably dermatological) advice | ||
| Oral ulceration | Withhold until discussed with specialist team | ||
| Hydroxychloroquine | |||
| Monitoring | Frequency | What to look for | What to do |
| Any visual disturbance, especially reduced visual acuity | Baseline opthalmological review. If normal examination and low risk (age <60 years, no liver disease, no retinal disease), 5 yearly visual acuity. High risk, annual visual acuity. |
Discuss with opthalmologist URGENTLY | |
| Leflunomide | |||
| Monitoring | Frequency | What to look for | What to do |
| Complete blood count (CBC) | Baseline Then every 2 weeks for the first 6 months If stable, 8 weekly. If co-prescribed with another immunosuppressant or hepatotoxic agent, 4 weekly |
WBC <3.5 x 109/L Neutrophils <2.0 x 109/L Platelets <150 x 109/L |
Discuss with specialist team immediately. |
| Liver function tests (LFTs) | Baseline Then every 4 weeks for the first 6 months If stable, 8 weekly. If co-prescribed with another immunosuppressant or hepatotoxic agent, 4 weekly |
AST, ALT, Alk Phos > twice the upper limit of reference range | Withhold until discussed with specialist team |
| Blood pressure | Baseline. Then at each visit |
BP >140/90mmHg | Treat. If blood pressure remains uncontrolled, discuss with specialist team |
| Abnormal bruising or severe sore throat | Check CBC immediately and withhold until results available | ||
| New or increasing dyspnoea or dry cough (pneumonitis) | Some teams perform baseline chest x-ray and respiratory function tests | Withhold and discuss URGENTLY with specialist team. Arrange chest x-ray and respiratory function tests | |
| Azathioprine | |||
| Monitoring | Frequency | What to look for | What to do |
| Complete blood count (CBC) | Baseline Then weekly for 6 weeks Then every 2 weeks until dose is stable for 6 weeks Then monthly Repeat CBC and LFT two weeks after a dose change |
WBC <3.5 x 109/L Neutrophils <2.0 x 109/L Platelets <150 x 109/L |
Withhold until discussed with specialist team. Measure 6-TGN and 6-MMP levels. |
| MCV > 105 fL | Check vitamin B12, folate and TSH. If abnormal, treat any underlying abnormality. Check 6-TGN level | ||
| Liver function tests (LFTs) | Baseline and then monthly | AST, ALT > twice the upper limit of reference range. | Withhold until discussed with specialist team. |
| Serum creatinine | Baseline and then every 6 months | Mild-to-moderate renal impairment (10-50 mL/minute) | Withhold until discussed with specialist team |
| Rash or oral ulceration | Withhold until discussed with specialist team | ||
| Abnormal bruising or severe sore throat | Withhold until CBC results available and discuss with specialist team | ||
| Cyclosporin | |||
| Monitoring | Frequency | What to look for | What to do |
| Complete blood count (CBC) | Baseline Then monthly until dose stable for 3 months Then 3-monthly |
Platelets <150 x 109/L | Withhold until discussed with specialist team |
| Liver function tests (LFTs) | Baseline Then monthly until dose stable for 3 months Then 3-monthly AST, ALT, or alkaline phosphatase more than two times the upper limit of the reference range |
AST, ALT, or alkaline phosphatase more than two times the upper limit of the reference range | Check for any other reason such as alcohol or drug interactions (including OTC medication), and discuss with specialist team |
| Creatinine | Baseline Then every two weeks until dose is stable for three months Then monthly. |
Creatinine increase > 30% from baseline | Repeat in one week, if still > 30% above baseline, withhold until discussed with specialist team. |
| Uric acid | Every 3 months. | Discuss persistently elevated uric acid with Rheumatology team and watch for development of gout and tophi. | |
| Electrolytes | Baseline Then every two weeks until dose is stable for three months Then monthly. |
Potassium increase to above the reference range | Use clinical judgement, and if necessary discuss with the specialist team |
| Fasting lipids | Baseline Then six monthly |
Significant increase in fasting lipids | Withhold until discussed with specialist team |
| Blood pressure | Baseline and then check every time patient attends clinic | BP >140/90mmHg | Treat. If blood pressure remains uncontrolled, discuss with specialist team |
| Abnormal bruising/bleeding | Check CBC immediately and withhold until discussed with the specialist team | ||
| Sodium aurothiomalate, injectable gold | |||
| Monitoring | Frequency | What to look for | What to do |
| Complete blood count (CBC) | Baseline and then at each injection | WBC <3.5 x 109/L Neutrophils <2.0 x 109/L Platelets <150 x 109/L |
Withhold until discussed with specialist team |
| Eosinophilia > 0.5 x 109/L | Caution and extra vigilance for increased eosinophilia (hypersensitivity reaction) | ||
| Urine dipstick | Baseline and then at each injection | 2+ proteinuria or more . | If infection present treat appropriately. If 2+ proteinuria or more persists, withhold until discussed with specialist team |
| Rash (usually itchy) or oral ulceration | Withhold until discussed with specialist team | ||
| Abnormal bruising or severe sore throat | Check CBC immediately and withhold until results are available | ||