DMARD monitoring in Primary Care

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.

Consultant 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 (see resources).
This guidance does not cover baseline pre-screening for initating DMARDS

Follow guidance in NICE CKS: Scenario: Monitoring of DMARDs

Please note:

• For mercaptopurine look at the requirements for azathioprine
• For mesalazine look at the requirements for sulphasalazine

Dermatology, please note:

Extra monitoring requirements to those listed in the resource above:

• 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 correct tube to use, see the Quick Reference Guide for Blood Science and Microbiology/Immunology Tests (see related guidelines, NHS Highland Intranet access required)

• 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. 
• 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
• Refer patients to advice from Versus Arthritis (see resources)

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

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