Education - ACR Guidelines
Guidelines for Monitoring Drug Therapy in Rheumatoid Arthritis
| These recommendations are for patients without concurrent illness or medication and have uncomplicated rheumatoid arthritis. See Pharmacological Strategies under the treatment of Rhuematoid Arthritis. Updated May, 2002 | ||||
| Drugs | Toxicities | Initial evaluation* | Symptoms | Laboratory/Examination |
| Non-steroidal anti-inflammatory | ||||
| Salicylates | gastrointestinal bleeding;ulceration | CBC, LFTs, creatinine | upset stomach, dark/black stool, edema abdominal pain, nausea/vomiting, shortness of breath | annual CBC, LFTs |
| Disease- modifying antirheumatics | ||||
| Leflunomide | Diarrhea, alopecia, rash, headache, theoretical risk of immunosuppression, infection | Hepatitis B and C serology in high-risk patients, CBC, creatinine, LFTs | Diarrhea, alopecia, intercurrent liver, gallbladder, and renal disease, pregnancy or delayed menses. Known teratogen. | CBC, creatinine, LFTs monthly for the first 6 months; every 1&150;2 months thereafter. For minor elevations in AST or ALT (<2-fold ULN), repeat testing in 2נ weeks. For moderate elevations in AST or ALT (>2-fold but <3-fold ULN), closely monitor, with LFTs every 2נ weeks and dosage reduction. For persistent elevations of AST or ALT (>2– or 3-fold ULN), discontinue leflunomide and eliminate with cholestyramine therapy; perform liver biopsy as necessary. Patients also taking MTX should have LFTs at least monthly. |
| Etanercept | None recognized | Assess for infections or risk factors for infections | Acute or chronic infections | Monitor for injection site reactions |
| Infliximab plus methotrexate | None recognized | Assess for infections or risk factors for infections | A cute or chronic infections | Monitor for infusion site reactions and see methotrexate below |
| Hydroxychloroquine | macular damage | eye exam if over 40 years old or prior eye disease | visual changes; funduscopic and visual fields every 6-12 mos | None |
| Sulfasalazine | myelosuppression | CBC and LFTs in patients at risk, G6PDH | photosensitivity, rash, myelosuppression | CBC every 2-4 wks/first 3 mos, then every 3 mos thereafter |
| Methotrexate | Myeloasuppression, hepatic fibrosis, cirrhosis, alopecia, pulmonary infiltrates or fibrosis | radiograph of chest, CBC, AST or ALT, alkaline, albumin, (hepatitis B&C in high risk patients) | myelosuppression, shortness of breath, nausea/vomiting, lymph node swelling | CBC, creatinine, LFTs monthly for the first 6 months; every 1-2 months thereafter. For minor elevations in AST or ALT (<2-fold ULN), repeat testing in 2נ weeks. For moderate elevations in AST or ALT (>2-fold but <3-fold ULN), closely monitor, with LFTs every 2-4 weeks and dosage reduction as necessary. For persistent elevations of AST or ALT (>2– or 3-fold ULN), discontinue MTX and perform liver biopsy as necessary. |
| Oral Gold | myelosuppression, proteinuria | CBC, urine dipstick for protein | myelosuppression, edema, rash, diarrhea | CBC, urine dipstick for protein every 4-12 wks |
| Intramuscular Gold | myelosuppression, proteinuria | creatinine, CBC, urine dipstick for protein, creatinine | myelosuppression, edema, rash, oral ulcers | platelet count, CBC, urine dipstick for protein every 1-2 wks/first 20 wks, then at the time of each injection |
| D-penicillamine | Myelosuppression, proteinuria | CBC, urine dipstick for protein, creatinine | myelosuppression, edema, rash | CBC, urine dipstick for protein every 2 wks until stable dose is reached, then every 1-3 mos |
| Azathioprine | myelosuppression, lymphoproliferative and hepatic disorders | LFTs, CBC, creatinine | myelosuppression | CBC and platelet count every 1-2 wks with with changes in dosage, then every 1-3 mos |
| Corticosteroids | ||||
| Prednisone <10 mg (or equivalent) | hypertension, hyperglycemia, osteoporosis | chemistry panel, BP, bone densitometry for high risk patients | BP at each visit, polyuria, polydipsia, edema, visual changes, weight gain, shortness of breath, fracture | urinalysis for glucose annually |
| Agents for refractory rheumatoid arthritis or severe extraarticular complications | ||||
| Cyclophosphamide (Cytoxan) | myelosuppression, malignancy, myeloproliferative disorders, hemorrhagic cystitis | platelet count, CBC, urinalysis, creatinine, AST or ALT | hematuria, myelosuppression | CBC and platelet count every 1-2 wks with changes in dosage, then every 1-3 mos, urinalysis & urine cytology every 6-12 mos after drug is stopped |
| Chlorambucil | myelosuppression, malignancy, myeloproliferative disorders, | CBC, AST or ALT, urinalysis, creatinine | myelosuppression | CBC and platelet count every 1-2 wks with with changes in dosage, then every 1-3 mos |
| Cyclosporin A | anemia, hypertension, renal insufficiency | CBC, creatinine, BP, uric acid, LFTs | edema, hypertrichosis, paresthesia, nausea, BP every 2 wks until stable dose is reached, then monthly | creatinine every 2 wks until stable dose is reached, then monthly; periodic CBC, potassium, and LFTs |
Guidelines for Monitoring Drug Therapy in Rheumatoid Arthritis
