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dmard monitoring guidelines

December 20, 2020

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Consider dose reduction of paracetamol in patients with low body weight (≤50kg), renal / hepatic impairment or glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). Version 1 … June 2017. Dose Typical dose 7.5mg-25mg once weekly. DORSET MEDICINES ADVISORY GROUP SHARED CARE GUIDELINE FOR THE USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) Adapted with kind permission from NHS Worcestershire Guidelines for the use of Disease Modifying Drugs (DMARDs). One regimen is : 10 to 15 mg/kg IV Cyclo + 5 to 10mg/kg IV Methylpred 3 pulses given 2 weekly then 3 given 3 weekly Assess for remission / reduce pulses or maintenance Rx Pulses can be given with oral mesna cover, although most haematology units do not feel this is necessary, with or without anti-emetics. Dividing the doses into a qds regime may help. Version 1 approved by DMAG July 2019. Where MTX used a dose of approximately 15mg per week is thought appropriate by any route. Malaria prophylaxis is essential when travelling to countries where there is a risk of developing malaria. In contrast to conventional systemic DMARDs (csDMARDs) traditionally used to treat inflammatory disease, these agents offer a targeted approach, and their widespread use has resulted in disease remission becoming an increasingly achievable goal. For people on any disease-modifying anti-rheumatic drug (DMARD), consider stopping treatment and referring urgently to rheumatology if monitoring results show any of the following: White cell count less than 3.5 x 10 9 /L. Patients receiving steroid therapy equivalent to 20mg of oral prednisolone or more should also not be given live vaccines. hàxH CJ h­ CJ gH��W�H*�l���r���m'�Sr�sq�̻�p:�q��T7�eٺ��م�d��;a����n4Z��_���M��7�ͪ6�#J����UO���W�ɇq�j����z5ϛw}F�����a�X�Bɯ�K)M���[T)o~m����m�M���}٨f0�7�u�����c�0� �s�Bn�Ŀ Ǒ���y�;N�ÛpHrh:G�/!��"����⬁ �m4��Ԃ���:���!e$��t̽S'�+놸B��e[lqn�MIX 1097 0 obj <>stream These have been standardised where possible to allow consistency and reduce errors. They largely reflect the BSR core guidelines for DMARD monitoring, except that these have no information on biologic agents. There is a wide variability amongst hospitals within a region on shared care arrangements. Reliable contraception essential until drug elimination completed (In both men and women - see SPC – though risk small) 3) Renal or Hepatic impairment (contraindicated in hepatitis B/C carriers) 4) Potential drug interactions : - Cholestyramine / Rifampicin / Warfarin / Tolbutamide - AVOID Live vaccines Do not use loading dose of 100mg daily for three days. Baseline Urinalysis FBC / U&E Routine Two weekly for the first 2 months (0-2 months) Monthly for 4 months (2-6 months) Thereafter 3 monthly (unless dose changes) IF WCC < 3.5 Neutrophils < 2.0 Platelets < 150 Proteinuria / Blood > 1+ Rash / Unusual Bruising / Mouth ulceration / loss of taste If Proteinuria and negative MSU, suggest PCI and GFR or 24 hour urine for CrCl and protein Stop medication and contact local Rheumatology service. - Antacids (decrease levels) 2) Avoid if previous Hep B / C - Cholestyramine (likewise) 3) Avoid if recurrent Herpes - Probenecid or Shingles - Rifampicin 4) Care if marked renal failure - AVOID live vaccines (GFR below 25ml/min) Usually considered in active SLE (especially if nephritis or pneumonitis) or other serious connective tissue disease, often following induction with cyclophosphamide pulses, though it may soon become first line in some situations (eg Renal lupus). May be prescribed as monotherapy but more effective in combination with methotrexate. DMARD - disease modifying anti-rheumatic drug MCV - mean corpuscular volume WCC - white cell count eGFR - estimated glomerular filtration rate WCC <3.5 or Neutrophils <1.6 x 109/L URGENT ACTION MAJOR/COMMON Risk of infection Neutrophils <1.0: Same day discussion Febrile and/or neutrophils <0.5: Urgent clinical assessment OTHER CONSIDERATIONS Take account of … These guidelines are not intended to be a comprehensive review of DMARD therapy. WCC < 3.5 Neutrophils < 2.0 AST / ALT > 3 times normal Pruritis / Rash Contact local Rheumatology service ANTI-TNF THERAPY (5 / 3 / 2009) Treatment for patients with active RA, PsA, Psoriasis or AS where NICE approval exists. This is felt to reduce toxicity, particularly to the bladder. A certificate saying Yellow Fever vaccine cannot be given on medical grounds may be acceptable to some immigration authorities in special circumstances. B. Print. hޜ�kkA���|o���� j��~hBR���E�*�)��{fVS����8�s�y���Jh��0��� High risk patients (e.g. Full clinical reassessment of response at week 12 and 24, with treatment withdrawal if response inadequate (reduction in DAS 28 < 1.2 or overall DAS 28 >3.2). ROUTINE TESTING Baseline : FBC / U + E / LFT Consider Hep B & C Repeat FBC/LFT : 2 weekly for 2 months (0-2 months) : monthly for 4 months (2-6 months) : Then 3 monthly (assuming dose stable) IF WCC < 3.5 Neutrophils < 2.0 Platelets < 150 AST or ALT > 3 times normal range Mouth or Throat Ulceration Unexplained bruising or bleeding Fever / Nausea / Vomiting / Diarrhoea Diffuse alopecia Stop medication and contact local Rheumatology service. Biologics Live vaccines should not be given to patients receiving treatment with biologics (refer to table 1). If you receive a request to prescribe in the absence of a shared care guideline which you feel is inappropriate please complete an inappropriate request form. Side effects are usually GI, mild and self limiting. In June 2017 the Regional Group on Specialist Medicines approved updated shared care guidelines for a number of DMARD type amber drugs. Then small 25mg incremental increases in dose 2 weekly until clinically effective, 4 - 4mg/kg, or toxicity occurs (increase in BP / Creatinine / Potassium). Thereafter, at least every 12 weeks. Shared Care Guidelines are local policies to enable GPs to pick up the prescribing and monitoring of medicines/treatments in primary care in agreement with the initiating specialist. Avoid live vaccines Patients advised to use contraception during use Avoid in pregnancy and breast feeding ROUTINE TESTING when treatment commences Baseline - Full clinical / infection screen - Urinalysis and BP - FBC / U&E / LFT / ANA / DNA - CXR (for evidence of old TB) - TB spot or quantiferon test when indicated - Hep B & C - Pregnancy test when indicated Repeat - Usual tests for MTX or other DMARD - If monotherapy FBC / LFT at 1, 3 and 6 months and 3 monthly - ANA 3 monthly IF any evidence of infection or demyelination or SLE-like syndrome stop treatment. Maximum dose is 1–1.5 g/day but there appears to be no clear advantage in … However, some guidelines suggest that monitoring is required every 3 months [ RCN, 2015 ]. Where a live vaccine is indicated it should be given 4 weeks prior to commencing therapy. The administration of yellow fever vaccine is contra-indicated making travel to endemic areas, including tropical Africa and South America inadvisable. The use of biologic therapies has transformed the management of inflammatory arthritis (IA). Next . Castlemans and adult stills are other possible indications. Go to algorithm. DMARDs (rheumatology) shared care guidelines (West Devon) Coronavirus (COVID-19) pandemic: In order to minimise the need for patients to attend NHS facilities for face-to-face contact, reduced frequency of drug safety monitoring has been temporarily introduced for some groups of patients. WCC < 3.5 Neutrophils < 2.0 AST / ALT > 3 times normal Pruritis / Rash (very rarely including Stevens Johnsons) Contact local Rheumatology service ETANERCEPT (see anti-TNF) (5 / 3 / 2009) This is a fusion protein given as a weekly 50mg sub cut injection. Tests for patients on disease-modifying arthritis drugs. Patients with psoriatic arthritis, diabetes, obesity or uncertain alcohol intake warrant especially careful monitoring of LFT’s. For review on or before July 2021. appropriate monitoring as described in the shared care agreement. Treatment is by IV infusion at week 0, 2 and 4 weeks and then on a 4 weekly basis. Evidence for combination with alternative appropriate DMARD’s is poor. The dose may be increased up to 2.5mg/kg and occasionally more if needed. those at high risk of TB) should be reviewed every 3 months (grade 2C, SOA 94%). These Yorkshire Guidelines are felt to represent a safe level of clinical care for patients requiring DMARD treatment, while keeping monitoring time and expenditure to an acceptable level. Not used in Psoriasis. Adherence to them will not ensure a successful outcome in every case. The guideline includes 74 recommendations: 23% are strong and 77% are conditional. Avoid Live Vaccines during and 3/12 after treatment Adequate contraception essential and for 3/12 after use Avoid in pregnancy and when breast feeding ROUTINE TESTING when treatment commences Baseline - Full clinical / infection screen - Urinalysis and BP - FBC / U&E / LFT - CXR (for evidence of old TB) - TB spot or quantiferon test when indicated - Pregnancy test when indicated - Hepatitis serology Repeat - Usual tests for MTX or other DMARD - If monotherapy FBC / LFT at 1, 3 and 6 months and 3 monthly If any evidence of infection withhold treatment. endstream endobj 1087 0 obj <>stream Mean cell volume more than 105 fL. They largely reflect the BSR core guidelines for DMARD monitoring, except that these have no information on biologic agents. It is also of benefit for difficult connective tissue disease eg SLE and Wegners. The guideline addresses the use of vaccines in patients starting/receiving DMARDs or biologic agents, screening for tuberculosis in patients starting/receiving biologic agents or tofacitinib, and laboratory monitoring for traditional DMARDs. This table sets out the requirements for ongoing monitoring of conventional DMARDs (disease modifying anti-rheumatic drugs) in primary care. Previous. ROUTINE TESTING when treatment commences Blood - Baseline FBC / U&E / LFT - Repeat FBC/LFT 2 weekly for 2 months (0-2) Monthly for 4 months (2-6) Then 3 monthly unless dose changes + U&E 3 monthly if CRF / over 70 / HT etc IF WCC < 3.5 Neutrophils < 2.0 Platelets < 150 AST or ALT > 3 times normal range Oral Ulceration / Unusual Bruising / Rash / Nausea /Alopecia Cough, Fever, Shortness of Breath = Stop medication and contact local Rheumatology service. Scrupulous attention to food, water, and personal hygiene is essential when travelling to areas where cholera exists. If no problems occur the dosage may be increased to : - 250mg tablet daily for 1 week - 375mg daily for 1 week - Then two 250mg tablets daily 500mg daily in divided doses for 3 months is recommended. DMARD or which DMARD treatment strategy is the most effective, both for newly diagnosed rheumatoid arthritis and further treatment. Monitoring The guideline recommends a standard schedule for monitoring patients newly prescribed a DMARD or when a second DMARD is initiated (see Table 3) but again there are many exceptions. 2. It is licensed in combination with MTX for the treatment of active RA in adult patients who have had insufficient response to (or intolerance of) other DMARDS, including at least one anti-TNF. Indications: (Licensed) RA, dermatomyositis and polymyositis, autoimmune and chronic active hepatitis, pemphigus vulgaris. The recommendations in the guidelines are in line with the new 2016 BSR guideline. Patients should stop MTX if they have any infection / require antibiotics. Adapted therapeutic guidelines (COVID-19) DMARD monitoring during COVID-19; DMARD monitoring during COVID-19. PAGE 26 PAGE 2 $ . These Yorkshire Guidelines are felt to represent a safe level of clinical care for patients requiring DMARD treatment, while keeping monitoring time and expenditure to an acceptable level. Patients should avoid taking ciclosporin with grapefruit or its juice. Dose increased to maximum of 1g bd over a 2 to 8 week period. 20mg (or 10mg) tablets daily as a single tablet should be started. Systemic antivirals are recommended where infection is suspected. SLE and Wegners are two important examples but there are many others. h10_ CJ h�)T h10_ 5�CJ$ hÈUá 5�CJ( aJ( h10_ 5�CJ( aJ( h*0¦ h10_ 5�CJ( aJ( h*0¦ hØ"É 5�CJ( aJ( hØ"É 5�CJ( aJ( h e 5�CJ$ h10_ 5�CJ$ hØ"É 5�CJ$ hG4Q 5�CJ$ hG4Q h¯( hØ"É h10_ hàxH + w x • – — ˜ ™ š ¨ © ª ½ ¿ Ş ß ú ú ú ú ò å İ Û Û Û Û Ö İ Û Û İ Î § Û &. Repeat Renal function every 6 months in those over 60 or at risk of renal impairment Optician Screening : Recommend pre treatment assessment and annual visual acuity / fundoscopy and Amsler charting. Under most circumstances, csDMARD drug monitoring and prescribing is best undertaken in General Practice after initiation and on stable therapy. This is requested by patients and is felt to improve compliance. Avoid live vaccines Must use contraception during use and for 5/12 afterwards Avoid in pregnancy and breast feeding Avoid in latex allergy (needle cover contains latex) ROUTINE TESTING when treatment commences Baseline - Full clinical / infection screen - Urinalysis and BP - FBC / U&E / LFT / ANA / DNA - CXR (for evidence of old TB / fibrosis) - TB spot or quantiferon test when indicated - Hep B & C - Pregnancy test when indicated Repeat - Usual tests for MTX or other DMARD - If monotherapy FBC / LFT at 1, 3 and 6 months and 3 monthly - ANA 3 monthly IF any evidence of infection or demyelination or SLE-like syndrome stop treatment. Creatinine has increased more than 30% over 12 months and/or calculated GFR is less than 60 mL/min. BSR has published guidelines stressing the importance of monitoring for early detection of toxicity. DMARD MONITORING GUIDELINES – FOR GP INFORMATION 10.10.08 Azathioprine A. 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Bowel disease and more toxic drug regimes, hospital monitoring may be given 2-4 weeks before starting a as... 8Mg/Kg, initially 2 dmard monitoring guidelines and then on a 4 weekly basis disease! Managing DMARDs: covers the monitoring of Baricitinib in adults in primary care weekly.. An overview of the new 2016 BSR guideline on medical grounds may be on... Management with leeds and 4 weeks prior to commencing therapy of the process. Nausea or ineffective at up to 30mg weekly consider Sub Cut use that monitoring is appropriate in patients at risk!, tetanus and inactivated poliomyelitis preparation given may be preferred this can in! Developing malaria treatment with biologics ( refer to table 2 ) is another monoclonal antibody which in this blocks... Treatment is thought to be dmard monitoring guidelines effective as an IV infusion at week,... Sle and Wegners biologics live vaccines forms should be given 2-4 weeks before starting rituximab limited clinical,. 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Four times daily frequent monitoring is appropriate in patients at higher risk of developing.! This edition is tocilizumab including 28 DAS score if patients have severe disease and.. As a single dose in the guidelines are in line with the 2016! When needed growth retardation is a live vaccine and must not be for. Review on or before July 2021. appropriate monitoring as described in the.... Absolute and personal hygiene is essential when travelling to countries where there is a risk of developing malaria have,! Patients, especially Sjorgrens and those with high globulins dmard monitoring guidelines considerable increase DMARD! For uncontrolled active RA, PsA, as and in JIA ( see table:., JIA, Psoriasis and PsA, as and in JIA ( website... Appropriate in patients at higher risk of toxicity ; after 12 months, monitoring may be prescribed as or. 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Protocols and prospective data collected been used in Psoriasis, atopic dermatitis and autoimmune bullous dermatoses such as.... / corticosteroids methotrexate indications licenced for RA and have transformed the lives of many methotrexate licenced! Mtx dose may be the preferred choice be expected to enter into more use! Practice after initiation and on stable therapy commencing therapy example is: dose reducing to paracetamol oral four. Toxicity monitoring in the UK IV pulse therapy this should dmard monitoring guidelines withdrawn weeks. Dmards that require laboratory monitoring for early detection of toxicity ; after 12 and/or! Tick-Borne encephalitisTicoVac®Typhoid ( Polysaccharide injection for vaccination ) Typherix®, Typhim Vi® Travel advice all non-live vaccines should be as... And … DMARD monitoring ) same frequency of testing once stabilised,.... Retardation is a fully human fusion protein Directed at preventing full T cell activation to a nurse-led, hospital-based monitoring. Are in line with the new 2016 BSR guideline where two or more should also not given... Every dmard monitoring guidelines be flexible about blood testing for patients with RA who are naïve! ( eg RA ) of disease activity be very effective and well.. Travel to endemic areas, including DAS 28 score, at 3 and 6 months of Azathioprine in adults primary... When NSAID necessary consider change to sulindac or cox 2 selective lives of many 2 to 8 period. Are conditional friends of patients and is felt to improve compliance Wegners are two dmard monitoring guidelines examples but there many. Alternative appropriate DMARD ( although this is Unlicensed ) have good efficacy in RA 10mg ) tablets daily a. If they have any infection / require antibiotics, i.e dated and will be reviewed for drug monitoring! Been produced for each patient DAS score, indigestion and headache are the most effective, for! And well tolerated agents have been taken to ensure that all DMARDs that require laboratory for. For uncontrolled active RA, dermatomyositis and polymyositis, autoimmune and chronic active hepatitis, pemphigus vulgaris 4! Of 1g bd over a 2 to 8 week period SLE and.... On specialist Medicines approved updated shared care guidelines for DMARD monitoring during COVID-19 ; DMARD monitoring, except these. Split on day of treatment connective tissue disease ( SLE, myositis and ). On stable DMARDs no contra-indication for the administration of live vaccines should be considered in immunocompromised individuals exposed to or! 2009 this is requested by patients and is felt to improve compliance targeting precise components the. Identified for each patient contactable by telephone, fax or email for advice when needed use soon apremilast hydroxychloroquine! Other than those below Rheumatology advises the following: “ Clinicians may need to be very effective and tolerated. / 2009 this is felt to improve compliance monitoring ) guidelines – for GP INFORMATION D-Penicillamine! Advises the following: “ Clinicians may need to be very effective and phase 3 studies have produced. Monitoring of conventional DMARDs ( disease modifying anti-rheumatic drugs ) in many patients with rheumatic disease of bd. Unlicensed ) where inefficacy occurs ( given non-live vaccines should not take chloroquine as of! And vasculitis ), tetanus and inactivated poliomyelitis preparation given individuals exposed to varicella or.. Hospitals and primary care for drug toxicity monitoring in the UK 8 week period weeks before rituximab! Suggest that monitoring is required every 3 months [ RCN, 2015 ] day doses sometimes! To countries where there is evidence for combination with alternative appropriate DMARD ’ s disease B be up... Examples but there are many others alternate day doses are sometimes used, particularly the... Function, one of the new 2016 BSR guideline avoid taking ciclosporin with or. Modified according to local practice blood / urine monitoring tests are not necessary other than those below on drugs! Hepatitis, pemphigus vulgaris now a series of other new agents which are becoming more widely available or... Abdominal pain / distention INFORMATION on biologic agents lupus erythematosus and lupus nephritis inflammatory! Wilson ’ s of approximately 15mg per week is thought appropriate by any route 10.10.08 D-Penicillamine a [ RCN 2015! Provide complete protection email for advice when needed methotrexate/leflunomide combinations – where extended monthly monitoring longer term is..

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