DMARD monitoring in Primary Care (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • North NHS Highland only
  • Primary and Secondary Care

Update: DMARD Monitoring Guidance

NICE CKS guidance on DMARD monitoring has recently been updated, introducing a risk based approach following BSR guidelines. This represents a change from current local arrangements.

A cross-system review with prescribing specialties and primary care is underway to agree how this should be applied within NHS Highland.

In the meantime, clinicians should continue to follow existing local monitoring arrangements in order to minimise any confusion which may inadvertently impact on patient safety.

Links to national guidance are for reference and do not in themselves indicate a change to local practice.

A further update will follow.

NICE CKS sets out the primary care monitoring requirements for DMARDs (disease modifying anti-rheumatic drugs) for individuals from age 18 years onwards. This guidance has been agreed to be used 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.

NB Consultant advice always takes precedence over this guidance.

This guidance does not cover baseline pre-screening for initiating DMARDS.

Please note: Extra monitoring requirements to those listed in NICE CKS

All specialisms: 

  • Mercaptopurine: look at the requirements for azathioprine
  • Mesalazine: As per BNF: Renal function should be monitored before starting, at 3 months, and then annually during treatment.
  • Olsalazine: As per BNF: Renal function should be monitored before starting, at 3 months, and then annually during treatment.

Dermatology only:

  • Methotrexate for psoriasis:
    • procollagen III every 3 months
  • Ciclosporin:
    • Increased frequency of testing: Every 2 weeks until dose is stable for 6 weeks.
      Then every month thereafter.
    • BP, blood glucose and lipids at baseline and at each attendance
For the majority of DMARDS, follow NICE CKS: Scenario: Scenario: General principles of managing DMARDs | Management | DMARDs | CKS | NICE

Further information

More detailed patient and GP information leaflets may be available from the relevant specialities such as those produced by the Rheumatology team (NHS Highland intranet access required).

Blood tubes

For the correct tube to use, see the Labs Test Directory | Right Decisions

Patients with symptoms of COVID-19

  1. Consider stopping medication
    • ** seek specialist advice first ** and seek specialist advice on when to re-start.
    • Dermatology note:
      The impact of systemic immunomodulatory and biological drugs for immune-mediated inflammatory skin disease on outcomes to COVID-19 infection is unknown. For this reason, current recommendations are for patients to stay on their prescribed medication, unless advised by their dermatology team. 
  2. Undertake additional blood tests after self-isolation and within two weeks of re-starting medication.
    • If results okay: revert to standard monitoring recommendations
    • If abnormal: seek specialist advice
  3. Refer patients to advice from Versus Arthritis (see resources)

Peri-operative management

For peri-operative management of DMARDs and biologics see NHS Highland leaflet: Stopping medication in infection or prior to surgery (NHS Highland intranet access required).

Referral

Information on when to refer is included in the NICE CKS: Scenario: Monitoring of DMARDS under General Principles: When to refer. 

Editorial Information

Last reviewed: 08/12/2022

Next review date: 31/12/2025

Author(s): Formulary Team.

Version: 3.2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): P Hannam, Formulary Pharmacist.

Document Id: FCR111

Related resources

Further information for Health Care Professionals

References

Further information for patients

Self-management information