Drug | Safety monitoring tests | |||||||
---|---|---|---|---|---|---|---|---|
Methotrexate | ||||||||
At 3 weeks, 6 weeks, 12 weeks, then every 3-6 months | Basic blood count with platelets + differential count, ALT | |||||||
Every 6 months | Creatinine (in case of impaired renal function, dose reduction) | |||||||
Hydroxychloroquine | ||||||||
No laboratory monitoring needed. Checkup by an ophthalmologist after 5 years of use | ||||||||
Sulfasalazine | ||||||||
At 3 weeks, 6 weeks, 12 weeks, then every 3-6 months | Basic blood count with platelets + differential count, ALT | |||||||
Leflunomide | ||||||||
At 3 weeks, 6 weeks, 12 weeks, then every 3-6 months | Basic blood count with platelets + differential count, ALT, blood pressure | |||||||
Note the long biological half-life. Should severe adverse effects occur, treatment should be interrupted and elimination of the drug from the body started (cholestyramine or medicinal charcoal) | ||||||||
Azathioprine | ||||||||
At 3 weeks, 6 weeks, 12 weeks, then every 3-6 months | Basic blood count with platelets + differential count, ALT | |||||||
Mycophenolate | ||||||||
At 3 weeks, 6 weeks, 12 weeks, then every 3-6 months | Basic blood count with platelets + differential count, ALT | |||||||
Ciclosporin | ||||||||
At 3 weeks, 6 weeks, 12 weeks, then every 3-6 months | Cretinine, blood pressure | |||||||
Biological antirheumatic drugs and JAK inhibitors | ||||||||
Often used concomitantly with methotrexate in which case monitoring protocol as for methotrexate, and additionally: | ||||||||
Adalimumab, etanercept, golimumab, certolizumab | ||||||||
1 month after initiation | Basic blood count with platelets (+ differential count) | |||||||
Infliximab | ||||||||
Before infusion, as considered appropriate by the physician | Basic blood count with platelets (+ differential count), ALT, CRP | |||||||
Abatacept | ||||||||
1 month after initiation | Basic blood count with platelets (+ differential count), ALT | |||||||
Tosilizumab and sarilumab | ||||||||
1 month after initiation | Basic blood count with platelets (+ differential count), ALT | |||||||
At 3 months | Lipid levels | |||||||
Rituximab | ||||||||
Before infusion | Tests used locally, and IgG monitoring | |||||||
Tofacitinib and baricitinib | ||||||||
At 3 weeks, 6 weeks, 12 weeks, then every 3-6 months | Basic blood count with platelets + differential count, ALT | |||||||
At 3 months | Lipid levels | |||||||
All drugs | ||||||||
Monitoring tests should also be performed 2-3 weeks after any increase in drug dose. |
Safety monitoring tests | Threshold values and procedure | ||||
---|---|---|---|---|---|
Blood tests | Leucocytes | Neutrophils | Lymphocytes | Platelets | ALT |
>3 | >1.0 | >0.5 | >100 | <2-3 × reference value | |
If the number of blood cells is below the reference range or ALT is elevated, medication should be reduced as considered necessary. However, mild lymphopenia and macrocytosis commonly occur in association with the use of methotrexate and azathioprine, as do slightly elevated ALT levels during the use of methotrexate, and these require no change to the treatment. If the results of laboratory tests fall outside the ranges specified in the table, medication should be interrupted and tests repeated in 1-2 weeks. Use of the drug can often be continued at lower doses, repeating the monitoring tests. A rheumatologist should be consulted, as necessary. If agranulocytosis develops, the patient should be referred to hospital. | |||||
The efficacy of medication should be assessed by a rheumatologist after 3 and 6 months. Before the visits, the following should be tested: basic blood count (complete blood count with differential), creatinine (eGFR, calculator Gfr Calculator), ALT, ALP, ESR, CRP, chemical screening of urine.
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