| Comorbid conditions | Pretreatment testing | Relevant drugs/monitoring | Notes |
| Infections |
| Serious infections | | - Hold immunosuppressive medications
| - Risk/benefit should be based on clinical judgment
|
| Hepatitis B past infection with natural immunity | - HBcAb positive
- HBsAb positive
- HBsAg negative
- LFTs
| - No change in recommended treatment, except for rituximab
| - Monitor HBV viral load every 6 to 12 months
- Prophylactic antiviral therapy recommended with the use of rituximab
|
| Hepatitis B current/chronic infection | - HBcAb positive
- HBsAb negative
- HBsAg positive
- HBeAg positive
- LFTs
| - Consult with hepatologist prior to treatment
| |
| Hepatitis C infection | | - Attempt to use non-hepatotoxic DMARDs initially
| - Manage in collaboration with hepatologist
|
| Tuberculosis | - PPD or interferon gamma release assay
| - All patients prior to a bDMARD or tsDMARD (eg, JAK inhibitors) and those at risk prior to cDMARD therapy
| - If positive, treat for latent tuberculosis, starting at least 1 month prior to starting immunomodulatory therapy
|
| Malignancy |
| Nonmelanoma skin cancer | | - All immunomodulatory agents
| - Routine skin cancer surveillance
|
| Melanoma skin cancer | | - cDMARDs preferred over bDMARDs or tsDMARDs; generally avoid abatacept and TNF inhibitors; prefer rituximab if bDMARD needed
| - Dermatology suggested follow-up surveillance per melanoma stage protocols
|
| Lymphoproliferative disorder | | - cDMARDs preferred over bDMARDs or tsDMARD; prefer rituximab if bDMARD needed
| - Manage in consultation with hematology and oncology
|
| Solid organ malignancy | | - If <5 years out, prefer cDMARDs over bDMARDs or tsDMARD; if >5 years out, no change in treatment
| - Manage in consultation with oncologist
|
| Cardiovascular disease |
| Congestive heart failure | | - Caution with NSAIDs, GCs
- TNF inhibitors may worsen moderate to severe congestive heart failure and should be avoided
| |
| Hypertension | | | |
| Hyperlipidemia | | - IL-6 inhibitors and tsDMARDs may increase lipids
| - Lipid panel
- IL-6: every 6 months
- tsDMARD: 6 to 8 weeks after drug start
|
| Other |
| Lung disease | - Chest radiograph and PFTs
| - Caution with agents that may exacerbate lung issues: MTX, LEF, abatacept, rituximab, gold, SSZ, TNF inhibitor
| - Avoid MTX in patients with significant or progressive ILD; bDMARDs may exacerbate COPD
|
| Demyelinating disorders | | | |
| Diabetes | - Blood glucose
- Hemoglobin A1C
| - GCs may worsen
- HCQ and SSZ may lower blood glucose
| - Caution patients on oral glucose-lowering agents to watch for hypoglycemia
|
| Kidney disease | | - Dose medications for GFR
- For severe kidney disease, avoid MTX, CSA
| |
| Gastrointestinal disease | - History of diverticulitis
| - Avoid IL-6 inhibitors and tsDMARDs, which may increase risk of diverticular and other gastrointestinal perforation
| - Higher risk with concomitant NSAIDs or GCs
|
| Pregnancy | | | - RA frequently remits during pregnancy
- Manage in consultation with OB-GYN
|
