DMARDS MONITORING GUIDELINES SELKIRK MEDICAL PRACTICE

Transcription

1 DMARDS MONITORING GUIDELINES SELKIRK MEDICAL PRACTICE LIST OF DRUGS INCLUDED: ACITRETIN (Neotigason) ADALIMUMAB AMIODARONE AMISULPIRIDE ARIPRAZOLE AZATHIOPRINE CICLOSPORIN CYCLOPHOSPHAMIDE CLOZAPINE DENOSUMAB ETANERCEPT ERYTHROPOIETIN HYDROXYCARBAMIDE HALOPERIDOL HYDROXYCHLOROQUINE LEFLUNOMIDE METHOTREXATE MYCOPHENOLATE OLANZAPINE PENICILLAMINE QUETIAPINE RISPERIDONE SODIUM AUROTHIOMALATE (GOLD/ MYOCRISIN) SULPHASALAZINE OTHER SALAZINES (ASACOL, PENTASA, MESALAZINE, OSALAZINE) TACROLIMUS 6 MERCAPTOPURINE ALWAYS REFER TO BNF FOR MORE DETAILS ON INDIVIDUAL DRUG MONITORING

2 ACITRETIN (Neotigason) LFTS, UE, Fasting Lipids Glucose prior to starting. Ensure effective contraception LFTS, fasting Cholesterol and TG every 4 weeks for first 2 months LFTS, fasting Cholesterol and TG every 3 months thereafter If abnormal results, monitor blood tests weekly If TG s over 5 refer to lipidologist. If over 10 stop drug. If ALT more than 3 times normal stop drug. ADALIMUMAB FBC/ CRP / LFTS every 2 weeks for 3 months, then every 4 weeks for 6 months, then every 3 months Renal function : if normal initially, every 6 months Monitor for possible signs infection including fever, sore throat, shingles, chickenpox AMIODARONE Before starting, check UE, K+, LFTS, ECG, CXR LFTS, TFTS (including T3) every 6 months Ask about cough or breathlessness (risk of pneumonitis) Wear high factor sunscreen if exposed to sun Raised ALT discuss with specialist/ withdraw drug. Raised T4 alone may not be significant, but raised T3/ T4 suggests thyrotoxicosis. Amiodarone withdrawn temporarily. Carbimazole may be needed Speak to specialist. AMISULPIRIDE LFTS, Glucose, Lipids, BMI at 3 months and 6 months required (antipsychotics will moderately raise prolactin levels)

3 ARIPIPRAZOLE LFTS, Glucose, Lipids, BMI at 3 months and 6 months required. AZATHIOPRINE FBC/LFTS/ UE weekly for 6 weeks, then every 2 weeks for next 6 weeks When dose stable, monthly FBC, LFTS. WBC less than 4 or neutrophils less than 2 STOP drug Rise in MCV common Check B12/ folate No need to discontinue drug Platelets less than 150 STOP drug ALT/ALP may be allowed to increase 2 times upper limit normal discuss with rheumatologist If mouth ulcers, severe sore throat, fever or abnormal bleeding urgent FBC and withhold drug 6 MERCAPTOPURINE Monitoring is identical to AZATHIOPRINE - please refer to AZATHIOPRINE advice CICLOSPORIN FBC, LFTS monthly for first 6 months then every 8 weeks UE every 2 weeks until dose stable for 3 months then monthly Care taken if NSAID added esp diclofenac monitor UE/ LFTS regularly Reduce dose if Creat rises more than 30% (even in normal range) Monitor BP regularly See BNF re side effects CYCLOPHOSPHAMIDE FBC, CRP, ESR, Blood Pressure, Urinalysis weekly for first 4 weeks, then every 2 weeks for next 2 months FBC, CRP, ESR, Blood Pressure monthly thereafter WBC less than 4, STOP drug Platelets less than 100, STOP drug If haematuria/ proteinuria STOP drug and discuss with Rheumatology Rash or mouth ulcers discuss with Rheumatology

4 CLOZAPINE Baseline BMI, Fasting lipids, Glucose, UE, LFTS, FBC, TFTS, Prolactin, Pulse and BP, ECG. FBC WEEKLY for 18 weeks, then every 2 weeks for 1 year, then every 4 weeks thereafter. Check BMI, LFTS, Glucose after 1 month 3 monthly BMI, Lipids, Glucose, Pulse, BP, ECG Annually check BMI, LFTS, UE, Fasting lipids, Fasting Glucose, Prolactin, Pulse, BP, ECG ECG interpretation available from cardiology Prolactin 1000 no action required Neutropenia/ agranulocytosis reported. If WBC less than 3 or neutrophils less than 1.5 STOP drug permanently and refer to haematologist. Fatal cardiomyopathy reported (often in first 2 months). Consider if persistent tachycardia. STOP drug and refer cardiology. DENOSUMAB Hypocalcaemia a contraindication, and careful monitoring of calcium recommended in patients predisposed to hypocalcaemia. Recommend good dental hygiene, and should see dentist regularly. Treatment is 6 monthly injections up to 3 years. Stop alendronate, strontium etc but continue Adcal Monitor UE/ Calcium if EGFR less than 30 Local guidelines require Calcium level prior to each injection ETANERCEPT FBC/ CRP every 2 weeks for 3 months, then every 4 weeks for 6 months, then every 3 months if dose stable LFTS every 4 weeks for 6 months, then every 3 months UE every 6 months if normal, more frequently otherwise Side effects include injection site reaction, headache, dizziness, dyspepsia, abdominal pain, sepsis, flu like illness, rash, mouth ulcers If Neutrophils 1.5, Platelets 100, or ALT more than 2 fold increase withhold drug and contact Rheumatology Rash, excess bruising or oral ulceration contact Rheumatology Live vaccines should not be given to patients on Etanercept If patient in close contact with chickenpox/ shingles STOP drug for 2 weeks and Varicella antibody checked. Discuss with Rheumatology If patient develops Shingles /Chickenpox, give high dose anti virals ERYTHROPOIETIN Monitor BP at least monthly. If BP greater than 180/100 on more than 2 consecutive occasions discuss with Renal service. Adjust antihypertensive treatment. Target HB is usually 10.5 to Renal physicians will usually advise on monitoring and injection frequency. For further advice see

5 HYDROXYCARBAMIDE Baseline FBC, UE, LFTs bone profile and Uric Acid 3 monthly FBC, UE, LFTs, bone profile and Uric Acid Protect skin from sun exposure Mainly used in CLL Main side effects are myelosuppression, nausea and skin reaction HALOPERIDOL LFTS, Glucose, Lipids, BMI at 3 months and 6 months required. HYDROXYCHLOROQUINE Baseline UE and LFTs Optometry assessment prior to starting if pre-existing visual impairment/ eye disease FBC every 6 months Annual optician review if visual symptoms refer to ophthalmology Side effects include rash, nausea, sun sensitivity, hair lightening, hearing disturbance. Usually reversible with dose reduction or stopping drug. LEFLUNOMIDE Baseline FBC, ESR, UE, LFTs and BP FBC/ ESR every 2 weeks for first 6 months, and then every 8 weeks if stable LFTs and BP every month for first 6 months, then every 8 weeks thereafter Alcohol should be avoided Avoid concomitant use of Cholestyramine, phenytoin, warfarin WBC less than 4 or neutrophils less than 2 withhold drug and discuss with rheumatology ALT consistently 2-3 fold above normal, discontinue and discuss with rheumatology Mouth ulcers/ Rash Withhold drug and check urgent FBC METHOTREXATE Baseline FBC, ESR, UE, LFTs, CXR (if background respiratory disease) FBC, ESR, LFTs every 2 weeks for first 3 months, and for 6 weeks after ANY increase in dose. Thereafter monthly, provided stable UE every 6 months or more frequently if deteriorating renal function DO NOT prescribe Septrin or Trimethoprim WBC less than 4 or neutrophils less than 2 STOP drug and inform Rheumatology Platelets less than 150, STOP drug and inform Rheumatology Allow up to 3 fold rise in ALT/alk phos Discuss rapid rises in LFTs

6 MYCOPHENOLATE FBC, LFTs, UE weekly for 4 weeks, then every fortnight for 8 weeks, then every month thereafter If Neutrophils less than 1.5 or Platelets less than 100 withhold drug and inform Rheumatology If ALT more than 2 fold increase withhold drug and inform Rheumatology Rash, bruising or oral ulceration URGENT FBC and withhold drug until result If in close contact with someone with Shingles/ Chickenpox, withhold drug for 2 weeks and check immunity with Varicella Antibodies. If develop symptoms, treat with high dose anti-virals OLANZAPINE LFTS, Glucose, Lipids, BMI at 3 months and 6 months required (antipsychotics will moderately raise prolactin levels) PENICILLAMINE Baseline FBC, UE, and Urinalysis Urinalysis every week until stable dose, then monthly FBC every 2 weeks until stable dose, then monthly Patient should be asked bout rash and mouth ulceration each visit If + proteinuria, recheck in 1 week and continue drug If ++ proteinuria, withhold drug and send MSU for infection. If MSU negative or proteinuria persists after treatment for infection, organise 24 hour protein collection, UE, Albumin and inform Rheumatology. If + proteinuria on more than one occasion proceed as per ++ If haematuria, check MSU. If MSU negative, withhold drug and investigate for other cause. Total WBC less than 4 or neutrophils less than 2 withhold drug and inform Rheumatology. If patient febrile AD- MIT Platelets less than 150 withhold drug and inform Rheumatology Rash: withhold drug until rash cleared and inform Rheumatology Mouth ulcers: check urgent FBC Altered taste is common with Penicillamine but often settles spontaneously Dyspepsia: may need to reduce dose

7 QUETIAPINE LFTS, Glucose, Lipids, BMI at 3 months LFTS, Glucose, Lipids, TFTS, BMI at 6 moths required. Prolactin levels may be moderately raised by antipsychotics. RISPERIDONE LFTS, Glucose, Lipids, BMI at 3 months LFTS, Glucose, Lipids, BMI at 6 months required. Prolactin levels may be moderately raised by antipsychotics. SODIUM AUROTHIOMALATE (GOLD/MYOCRISIN) IM version of gold therapy. Test dose 10mg given then 50mg weekly if no adverse reaction FBC and URINALYSIS at each injection Ask patients about rash, pruritis, or mouth ulcer prior to each injection If rash/ pruritis is mild, reduced dose to mg If severe, withhold drug If neutrophils < 1.5, or Platelets < 100 withhold drug and contact Rheumatology If 2+ proteinuria/ haematuria on more than one occasion (and MSU negative) withhold drug and contact Rheumatology Mouth ulceration: withhold drug Abnormal bruising/ sore throat: urgent FBC

8 SULPHASALAZINE Baseline FBC, ESR and LFTs FBC, ESR, LFTs every month for the first 3 months FBC, ESR, LFTs every 3 months thereafter, provided they have been stable Return to monthly monitoring after any dose increase WBC < 4.0 or Neutrophils < 2.0 STOP drug and inform Rheumatology Platelets < 150 STOP drug and inform Rheumatology ALT/ ALP may be allowed 3 times upper limit of normal, but any rapid changes should be discussed Headache/ GI disturbance common early on. Dose reduction may help Discuss with Rheumatology if in doubt Rash: STOP drug until rash cleared and discuss with Rheumatology Abnormal bruising: check URGENT FBC and withhold drug OTHER SALAZINES (Asacol, Pentasa, Mesalazine, Osalazine) FBC, ESR, UE, LFTs, and Urinalysis every 3 months for the first year then every 6 months thereafter WBC < 4.0 or Neutrophils < 2.0 STOP drug and discuss with consultant Platelets < 150 STOP rug and discuss with consultant Abnormal LFTs may be allowed up to 3 times upper limit of normal but rapid changes should be discussed Haematuria/ proteinuria on more than 1 occasion (and MSU negative) : Stop drug and discuss with consultant Adverse reactions include diarrhoea, nausea, vomiting, rash/ urticaria, and nephritis/ nephrotic syndrome TACROLIMUS (ADVAGRAF) UE, BP every 2 weeks for first 3 months, then monthly thereafter FBC, LFTs every month for first 3 months, then every 3 months thereafter Lipids/ Glucose every 6 months Tacrolimus levels checked at secondary care, but should be checked if renal function deteriorates, or possible drug interactions (BNF) Side effects include myalgia, tremor, fatigue, headache, pareasthesia, nausea Treatment should be withheld and consultant contacted if: Creatinine rise 30% above baseline Platelets < 100 Rise in BP above normal range Potassium above normal range More than 2 fold increase in ALT Abnormal bruising Do NOT take grapefruit juice, Ibuprofen, St Johns Wort, Nifedipine and potassium sparing diuretics with Tacrolimus