Version June 2024
| Drug class | Drugs | Ongoing monitoring via system review and physical examination* | Ongoing laboratory monitoring and other testing¶Δ |
| Nonsteroidal antiinflammatory drugs (eg, naproxen, ibuprofen, aspirin) | Dyspepsia, nausea/vomiting, abdominal pain, edema, blood pressure | CBC and complete metabolic panel (electrolytes, creatinine, albumin, transaminases) every 6 months | |
| Glucocorticoids | Mood, weight gain, visual changes, weakness, polyuria, polydipsia, edema, infection, blood pressure | Diabetes screening, lipids, bone mineral density testing | |
| Conventional synthetic disease-modifying antirheumatic drugs (csDMARDS) | Hydroxychloroquine | Visual change, skin color change, paresthesia◊ | Ophthalmologic evaluation for retinal toxicity◊ |
| Sulfasalazine | Headache, nausea, diarrhea, photosensitivity, symptoms of myelosuppression, hepatotoxicity, rash | CBC, aminotransferases and creatinine every 2 to 4 weeks for the first 3 months or after increasing the dose, every 8 to 12 weeks for months 3 to 6, then every 12 weeks | |
| Methotrexate§ | Stomatitis, alopecia, diarrhea, nausea/vomiting, flu-like symptoms, shortness of breath, symptoms of myelosuppression, hepatotoxicity, infection, lymph node swelling, pregnancy | CBC, aminotransferases, and creatinine every 2 to 4 weeks for the first 3 months or after increasing the dose, every 8 to 12 weeks for months 3 to 6, then every 12 weeks | |
| Leflunomide§ | Nausea/vomiting, diarrhea, shortness of breath, paresthesia, hepatotoxicity, weight loss, blood pressure, pregnancy | CBC, aminotransferases, and creatinine every 2 to 4 weeks for the first 3 months or after increasing the dose, every 8 to 12 weeks for months 3 to 6, then every 12 weeks | |
| Minocycline | Hyperpigmentation, dizziness, falls | None after baseline | |
| Azathioprine | Diarrhea, nausea/vomiting, symptoms of myelosuppression, infection | CBC and platelet count every 1 to 2 weeks, with changes in dose every 1 to 3 months thereafter | |
| Biologic DMARDs (bDMARDs) | TNF inhibitors (eg, etanercept, infliximab, adalimumab, certolizumab pegol, and golimumab) | Infection, malignancy, demyelination, congestive heart failure, autoimmune phenomenon | No routine laboratory monitoring (unless also receiving a concurrent conventional DMARD) |
| IL-6 inhibitors (eg, tocilizumab and sarilumab) | Infection, symptoms of myelosuppression (PMNs and platelets), demyelination, hepatotoxicity, gastrointestinal perforations | CBC with differential (neutrophils) and LFTs every 4 to 8 weeks until stable, then every 3 months. Lipids 4 to 8 weeks after starting therapy, then every 6 months. | |
| Anti-CD20 antibodies (ie, rituximab) | Infection, PML, symptoms of neutropenia | CBC every 2 to 4 months | |
| CTLA4 Ig inhibitor (ie, abatacept) | Infection, COPD exacerbation, malignancy | No routine laboratory monitoring (unless also receiving a concurrent conventional DMARD) | |
| IL-12/23 inhibitor (ie, ustekinumab) | Nasopharyngitis, upper respiratory infection, headache | No routine laboratory monitoring (unless also receiving a concurrent conventional DMARD) | |
| IL-17 injhibitors (ie, ixekizumab, secukinumab, brodalumab, bimekizumab) | Infection, nasopharyngitis, headache | No routine laboratory monitoring (unless also receiving a concurrent conventional DMARD) | |
| IL-23 inhibitor (ie, guselkumab, risankizumab) | Upper respiratory infection, headache, fatigue, injection site reactions | No routine laboratory monitoring (unless also receiving a concurrent conventional DMARD) | |
| Targeted synthetic DMARDs (tsDMARDs) | JAK inhibitors (eg, tofacitinib, baricitinib, and upadacitinib) | Infection, zoster, symptoms of myelosuppression, hepatotoxicity, malignancy, gastrointestinal perforation | CBC with differential, creatinine, LFTs (transaminases, albumin, bilirubin) every month for 3 months, then every 3 months; lipids 6 to 8 weeks after drug start |
| PDE4 inhibitor (ie, apremilast) | Diarrhea, nausea/vomiting, headache | No routine laboratory monitoring (unless also receiving a concurrent conventional DMARD) |
These drugs are commonly used for the treatment of inflammatory arthritis (eg, rheumatoid arthritis, psoriatic arthritis, spondyloarthritis). Not all drugs are approved for all uses by all regulatory agencies.
These are general guidelines. Patients should be assessed on an individual basis to determine if they require additions or other modifications to the monitoring noted in this table.CBC: complete blood cell count (hematocrit, hemoglobin, white blood cell count, including differential white blood cell count and platelet counts); COPD: chronic obstructive pulmonary disease; IL-6: interleukin 6; JAK: Janus kinase; LFTs: liver function tests; PDE4: phosphodiesterase-4; PML: progressive multifocal leukoencephalopathy; PMNs: polymorphonuclear leukocytes; TB: tuberculosis; TNF: tumor necrosis factor.
* Confirm that immunizations are up to date in all patients.
¶ Screening for latent TB prior to all biologic DMARDs and prior to use of a JAK inhibitor, and repeat TB testing in patients at increased risk of or with known exposure to TB and patients treated for latent TB with potential ongoing exposure.
Δ Patients receiving a biologic DMARD or JAK inhibitor should also continue appropriate monitoring for concurrent conventional DMARD therapies.
◊ Refer to the UpToDate topic review on antimalarial drugs in the treatment of rheumatic disease for a detailed discussion of appropriate screening procedures for hydroxychloroquine-related ophthalmologic toxicity.
§ In patients receiving methotrexate and leflunomide in combination: CBC, creatinine, albumin, and transaminases every 2 to 4 weeks for the first 3 months or following dose increase, every 4 weeks for the next 3 months, then every 3 months.آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
