Monitoring strategies for drug treatment of rheumatoid arthritis

Drugs	Ongoing monitoring via system review and physical examination*	Ongoing laboratory monitoring and other testing^¶^Δ
Salicylates, NSAIDs	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.
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.
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.
Rituximab	Infection, PML, symptoms of neutropenia	CBC every 2 to 4 months.
Abatacept	Infection, COPD exacerbation, malignancy	No routine laboratory monitoring (unless also receiving a concurrent conventional DMARD).
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.

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.

NSAIDs: nonsteroidal antiinflammatory drugs; CBC: complete blood cell count (hematocrit, hemoglobin, white blood cell count, including differential white blood cell count and platelet counts); TB: tuberculosis; TNF: tumor necrosis factor; DMARD: disease-modifying antirheumatic drug; IL-6: interleukin 6; PMNs: polymorphonuclear leukocytes; LFTs: liver function tests; PML: progressive multifocal leukoencephalopathy; COPD: chronic obstructive pulmonary disease; JAK: Janus kinase.
* 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.

Adapted from:

Guidelines for monitoring drug therapy in rheumatoid arthritis. American College of Rheumatology Ad Hoc Committee on Clinical Guidelines. Arthritis Rheum 1996; 39:723.
American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the Management of Rheumatoid Arthritis: 2002 Update. Arthritis Rheum 2002; 46:328.
Saag KG, Teng GG, Patkar NM, et al. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Rheum 2008; 59:762.
Singh JA, Saag KG, Bridges SL Jr, et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol 2016; 68:1.

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Monitoring strategies for drug treatment of rheumatoid arthritis