Disease-Modifying Anti-rheumatic Drugs
Definition: Disease-modifying anti-rheumatic drugs (DMARDs) are immunosuppressive and/or immunomodulatory drugs designed to influence the course of a disease. People taking DMARDs require regular monitoring due to the risk of adverse effects, such as myelosuppression; gastrointestinal, renal, hepatic, and pulmonary toxicity; and increased risk of infection.
Adverse effects
Pulmonary toxicity
Rash/allergic reaction
Hepatic toxicity
Hair loss
Renal toxicity
Neuropathy
Gastrointestinal adverse effects
Damage to the retina
Myelosuppression
Infections
General Management Principals
Biological DMARDs require clinical review in secondary care at least 6 monthly. Monitoring bloods tests are usually undertaken at these appointments. Primary care do not usually require drug monitoring in primary care.
Follow local recommendations in local guidelines when prescribing and monitoring a DMARD.
Values useful indicators. However trends also important ie a rapid rise or fall, or a consistent downward/upward trend warrants extra vigilance.
Conventional DMARDs, once a person has been stabilized on treatment, shared care may be in place between primary and secondary care, with primary care carrying out ongoing prescribing and monitoring with review in secondary care when appropriate
Monitor for adverse effects or complications of treatment
Individual DMARDs have different prescribing and monitoring requirements.
Be aware that major toxicity with DMARDs can occur during intercurrent illness, particularly if there is impairment of renal function or sepsis.
People on DMARDs are more prone to infection, especially in the first 6 months of treatment - seek urgent advise if in contact with shingles/chickenpox, offer vaccinations, live vaccines should be avoided.
Be aware of possible drug interactions with DMARDs
Ensure that people on DMARDS have been provided with suitable patient information leaflets, such as those from Arthritis Care, Arthritis Research UK, and National Rheumatoid Arthritis Society.
When to refer
Consideration of stopping treatment and urgent rheumatology referral if any of the following monitoring results
Biological DMARDs consider stopping and urgent referral
Consider stopping treatment and referral if the person develops any of the following signs/symptoms
Creatinine has increased by more than 30% over 12 months and/or calculated glomerular filtration rate (GFR) is lower than 60 mL/min. - repeat 1 week - if still more than 30% from baseline withhold and discuss with specialist team.
Unexplained eosinophilia higher than 0.5 x 109/L.
Neutrophils lower than 1.6 x 109/L.
Alanine aminotransferase (ALT) and/or aspartate transaminase (AST) higher than 100 U/L.
Mean cell volume higher than 105 fL. - Check B12, folate and TSH levels - if abnormal treat/ normal discuss with specialist.
Platelet count lower than 140 x 109/L.
White cell count lower than 3.5 x 109/L.
Unexplained reduction in albumin lower than 30 g/L.
Urinary protein 2+ or more - check mid-stream urine sample - if evidence of an infection, treat appropriately, if sterile and 2+ proteinuria or more persists on two consecutive measurement, withhold until discussed with specialist team.
Blood pressure higher than 140/90mmHg - if on cislosporin stop and discuss with specialist / other DMARDS manage in accordance to hypertension guidelines.
Fever
Unexplained bruising, or bleeding
Sore throat
Nausea, vomiting, diarrhoea or weight loss
Skin/mucosal reaction, for example rash, pruritus, mouth, or throat ulceration
Diffuse alopecia
Breathlessness, infection or cough.
Peripheral neuropathy
Cough, haemoptysis, or weight loss (symptoms of tuberculosis).
Signs or symptoms of heart failure, or worsening heart failure.
Shortness of breath or dry cough (symptoms of interstitial lung disease).
Skin rashes (be aware of lupus-like syndrome and erythema nodosum for people taking azathioprine).
Abdominal pain or new abdominal symptoms.