DMARD monitoring during COVID-19

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This table sets out the requirements for ongoing monitoring of conventional DMARDs (disease modifying anti-rheumatic drugs) in primary care. This guidance has been agreed across all specialities in NHS Highland. Some patients will require additional monitoring due to the severity of their condition or other specific factors: in these cases, the consultant will inform the GP of the specific monitoring required. A consultant’s advice always takes precedence over this guidance. More detailed patient and GP information leaflets may be available from the relevant specialities such as those produced by the Rheumatology team. This guidance does not cover baseline pre-screening for initiating DMARDs.

COVID-19
This advice has been modified to protect patients from unnecessary health care visits and help preserve capacity in primary care for an interim period during the COVID-19 pandemic. 

For patients with symptoms of COVID-19:

  • Consider stopping medication - seek specialist advice first - (see “Should patients cease their medication as a precaution?” advice from BSR) and seek specialist advice on when to re-start
  • Undertake additional blood tests after self-isolation and within two weeks of re-starting medication
  • If results okay—revert to monitoring recommendations; if abnormal—seek specialist advice
  • Refer patients to advice from Versus Arthritis

Drug
and any specific monitoring requirements

Standard NHS Highland monitoring requirements 

NHS Highland modified monitoring during COVID-19
After start of treatment AND after each dose increase: Test FBC, LFTs, creatinine/eGFR
Azathioprine OR mercaptopurine
TMPT at baseline
Every 2 weeks until dose is stable for 6 weeks.
Then every month for 3 months.
Then every 3 months thereafter.
2, 6 and 12 weeks
Then every 6 months
Leflunomide monotherapy
BP and weight at each attendance
Methotrexate monotherapy
Dermatology (psoriasis patients only): procollagen III every 3 months
Leflunomide/ Methotrexate combination 
As for separate drugs
Every 2 weeks until dose is stable for 6 weeks.
Then every month for 9 months.
Then every 3 months thereafter.
2, 6 and 12 weeks
Then every 3 months
Sulfasalazine OR mesalazine Every 2 weeks until dose is stable for 6 weeks.
Then every month for 3 months.
Then every 3 months.
Stop monitoring at 12 months.
2, 6 and 12 weeks
Then every 6 months for 1 year
Ciclosporin
BP and blood glucose at each attendance
Every 2 weeks until dose is stable for 6 weeks.
Then every month for 9 months.
Then every 3 months thereafter.

2, 6 and 12 weeks
Then every 3 months

Mycophenolate Every 2 weeks until dose is stable for 6 weeks.
Then every month for 9 months.
Then every 3 months thereafter.
At 2, 6 and 12 weeks
Then every 6 months 
Tacrolimus
BP and blood glucose at each attendance
Every 2 weeks until dose is stable for 6 weeks.
Then every month for 9 months.
Then every 3 months thereafter.
Every 2 weeks until dose is stable
Then at 6 and 12 weeks
Then 3 monthly
Hydroxochloroquine Annual review by optometrist Consider suspending annual eye assessment with ophthalmologist advice

For all other combinations, follow the monitoring for the DMARD with the highest frequency of tests. No additional tests are needed.
Key: FBC = full blood count, LFTs = liver function tests, eGFR = estimated glomerular filtration rate, TPMT = thiopurine methyltransferase 

Reference: 

  • NHS Highland DMARD monitoring guidance
  • NHS Forth Valley: Modified NPT monitoring during COVID-19
  • Specialist Pharmacy Service guidance on the management of drugs requiring monitoring during COVID-19.
Editorial Information

Last reviewed: 15 April 2020

Next review: 15 July 2020

Author(s): Rheumatology, Dermatology, Neurology, Gastro-intestinal and Renal consultants

Approved By: Awaiting approval from TAM subgroup of ADTC

Document Id: COVID008