Indications: (Licensed) RA, dermatomyositis and polymyositis, autoimmune and chronic active hepatitis, pemphigus vulgaris. These guidelines are not intended to be a comprehensive review of DMARD therapy. Timing of dose is not important. DORSET MEDICINES ADVISORY GROUP SHARED CARE GUIDELINE FOR THE USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) Adapted with kind permission from NHS Worcestershire Guidelines for the use of Disease Modifying Drugs (DMARDs). (BSR) produced its second edition of DMARD monitoring guidelines for rheumatologists but this was considered by the committee for evaluation of guidelines of the Royal College of Physicians to be more appropriate as a ‘practical tool’ than guideline. MYCOPHENOLATE MOFETIL (4 / 3 / 2009) When commencing treatment the following should be considered when using this form of mycophenolate (ie NOT Myofortic) 1) Contraindicated in pregnancy 5) Potential drug interactions and breastfeeding. The administration of yellow fever vaccine is contra-indicated making travel to endemic areas, including tropical Africa and South America inadvisable. Dose: Grade of evidence: A Typical regimen: 125–250 mg/day increasing by 125 mg every 4 weeks to 500 mg/day. Mean cell volume more than 105 fL. It is licenced and approved by NICE for uncontrolled active RA, PsA, AS and in JIA (see website). This is requested by patients and is felt to improve compliance. If injection site reaction try topical (or oral) anti-histamine / corticosteroids. In other specialties usage is increasing, notably for inflammatory bowel disease and uveitis. It is licensed in combination with MTX for the treatment of active RA in adult patients who have had insufficient response to (or intolerance of) other DMARDS, including at least one anti-TNF. Next . Depending on the DMARD being monitored, results needing immediate discussion with the specialist team (whilst withholding the drug) include: White cell count less than 3.5 x 10 9 /L. hàxH CJ ; Scenario: Azathioprine: covers the monitoring of azathioprine in adults in primary care. Items highlighted in bold are felt to be of particular importance. The guideline addresses the use of vaccines in patients starting/receiving DMARDs or biologic agents, screening for tuberculosis in patients starting/receiving biologic agents or tofacitinib, and laboratory monitoring for traditional DMARDs. BSR has published guidelines stressing the importance of monitoring for early detection of toxicity. Creatinine has increased more than 30% over 12 months and/or calculated GFR is less than 60 mL/min. DMARD MONITORING GUIDELINES – FOR GP INFORMATION 10.10.08 Leflunomide A. If no problems occur the dosage may be increased to : - 250mg tablet daily for 1 week - 375mg daily for 1 week - Then two 250mg tablets daily 500mg daily in divided doses for 3 months is recommended. The patients who are receiving DMARDs for non-rheumatological conditions do not have access to a nurse-led, hospital-based blood monitoring service. Where MTX used a dose of approximately 15mg per week is thought appropriate by any route. There is evidence for use both as monotherapy or in combination with MTX. MTX dose may be split on day of treatment or taken twice weekly if side effects occur. There is a wide variability amongst hospitals within a region on shared care arrangements. ROUTINE TESTING when treatment commences Baseline FBC / U&E / LFT Opthalmological screening recommended if pre- existing ocular pathology or visual disturbance, impaired renal function or over the age of 60. Print. Avoid Live Vaccines during and 3/12 after treatment Adequate contraception essential and for 3/12 after use Avoid in pregnancy and when breast feeding ROUTINE TESTING when treatment commences Baseline - Full clinical / infection screen - Urinalysis and BP - FBC / U&E / LFT - CXR (for evidence of old TB) - TB spot or quantiferon test when indicated - Pregnancy test when indicated - Hepatitis serology Repeat - Usual tests for MTX or other DMARD - If monotherapy FBC / LFT at 1, 3 and 6 months and 3 monthly If any evidence of infection withhold treatment. Here too it has proved to be effective and phase 3 studies have been completed. Under most circumstances drug monitoring and prescribing is best undertaken in General Practice. Subsequently if no problems occur the dose is usually increased weekly to 100mg daily and then 150mg daily taken at the same time or in divided doses with meals. This should be prescribed in combination with methotrexate, or an alternative appropriate DMARD (although this is unlicensed). Not used in Psoriasis. * More frequent monitoring is appropriate in patients at higher risk of toxicity; After 12 months, monitoring may be discontinued. Neutrophils less than 1.6 x 10 9 /L. Mean cell volume more than 105 fL. Table 1: PICO characteristics of review question Population Adults with RA who are DMARD naïve. There are now a series of other new agents which are becoming more widely available. The results of the audit have been with the local hospitals. ROUTINE TESTING FBC and urine dipstix : Weekly for the first 16 - 20 injections FBC monthly thereafter Always check urine before each injection Some clinicians may prefer FBC with each injection IF WCC < 3.5 Neutrophils < 2.0 Platelets < 150 Proteinuria / Blood > 1+ (Where protein detected do MSU, and if negative check PCI and GFR or 24 hour urine collection for CrCl and protein) Rash / Unusual Bruising or Jaundice Mouth or Throat Ulceration / Gum or GI bleeding Nitroid reactions / anaphylaxis Stop medication and contact local Rheumatology service. 0 The major ones include : Osteoporosis (Always consider DXA / prophylaxis) Weight gain Thin skin / purpura / bruising / acne Hypertension Diabetes (regular urine checks) Cataracts Myopathy Mental disturbance Rapid dose reduction or discontinuation of chronic therapy can lead to life threatening Addisonian crisis and should always be medically supervised. DMARD MONITORING GUIDELINES – FOR GP INFORMATION 10.10.08 Mycophenolate mofetil A. Revised BSR guidance was published in early 2008 and was intended to be modified according to local practice. These Yorkshire Guidelines are felt to represent a safe level of clinical care for patients requiring DMARD treatment, while keeping monitoring time and expenditure to an acceptable level. Routine blood / urine monitoring tests are not necessary other than those below. WCC < 3.5 Neutrophils < 2.0 AST / ALT > 3 times normal Pruritis / Rash Contact local Rheumatology service ANTI-TNF THERAPY (5 / 3 / 2009) Treatment for patients with active RA, PsA, Psoriasis or AS where NICE approval exists. It may be expected to enter into more widespread use soon. Reports of association with bowel perforation, so low threshold for investigation of abdominal pain / distention. However, some guidelines suggest that monitoring is required every 3 months [ RCN, 2015 ]. - Antacids (decrease levels) 2) Avoid if previous Hep B / C - Cholestyramine (likewise) 3) Avoid if recurrent Herpes - Probenecid or Shingles - Rifampicin 4) Care if marked renal failure - AVOID live vaccines (GFR below 25ml/min) Usually considered in active SLE (especially if nephritis or pneumonitis) or other serious connective tissue disease, often following induction with cyclophosphamide pulses, though it may soon become first line in some situations (eg Renal lupus). Initial dose is usually 15mg once weekly, For each drug a single reference sheet outlining recommended drug monitoring tests, which should be done in order to minimise the risk of toxicity, is enclosed. ABATACEPT 5 / 3 / 2009 This is a fusion protein directed at preventing full T cell activation. In contrast to conventional systemic DMARDs (csDMARDs) traditionally used to treat inflammatory disease, these agents offer a targeted approach, and their widespread use has resulted in disease remission becoming an increasingly achievable goal. Sore throat / ulceration might be a rare late complication related to neutropaenia so check FBC TOCILIZUMAB 4 / 3 / 2009 This is a mouse / human monoclonal antibody directed against IL6. Indications: (Unlicensed) RA, systemic lupus erythematosus and lupus nephritis and inflammatory myopathy such as dermatomyositis and polymyositis. If nausea or ineffective at up to 30mg weekly consider Sub Cut use. :��%�g�\�T� }r �$k˜P'�Y����~�]z]�o躂�o Zej� Updated DMARD-type shared care guidelines. @�\]y+s�. This section on DMARD’S is devoted to these new agents. For RA this is when two or more DMARD’S have failed (including methotrexate), and 2 BSR assessments for activity of RA have been done more than 4 weeks apart to establish eligibility. Tick-borne encephalitisTicoVac®Typhoid (Polysaccharide injection for vaccination)Typherix®, Typhim Vi® Travel Advice All non-live vaccines should be given as appropriate. Then small 25mg incremental increases in dose 2 weekly until clinically effective, 4 - 4mg/kg, or toxicity occurs (increase in BP / Creatinine / Potassium). Formal opthalmological screening is also suggested when : 1) A cumulative dose of 500grams, which is equivalent to 3.4 years of 200mg bd or 6.8 years of 200mg daily 2) If doses of > 6.5mg/kg/day are used. Full clinical reassessment of response at week 12 and 24, with treatment withdrawal if response inadequate (reduction in DAS 28 < 1.2 or overall DAS 28 >3.2). Patients taking hydroxychloroquine should not take chloroquine as part of their malaria prophylaxis regime. No routine monitoring is necessary with apremilast, hydroxychloroquine, mepa-crine or minocycline. 2. �,=,o5Lo��`f�lxp����U�y�1]9�� 6�����mx����l�d�� Uٴ��wR�I]a�aŔ��W]�̝-��MNS������9�=��N|��0���$����A������+@���r�D"��(e Be� >�K�~�g`5� �Y�X���� -KEfk```\�������//X�ǀhXL@4 J�l}Ӏ4�� ���� H3�]� �200 x�d Combined Adsorbed diphtheria (low dose), tetanus and inactivated poliomyelitis preparation given. Following any dose changes repeat FBC one month after dose increase then revert to usual monitoring regime if stable. Version 1 approved by DMAG July 2019. 2) Considered teratogenic. It is licensed and approved by NICE for the treatment of RA with MTX where patients have failed to respond or are intolerant of DMARDS including at least one anti-TNF (see website). Version 1 … Systemic antivirals are recommended where infection is suspected. Treatment response at three months should be carefully assessed including 28 DAS score. It is also of benefit for difficult connective tissue disease eg SLE and Wegners. 1.3 PICO table For full details see the review protocol in appendix A. Their use is increasing in line with their approval by NICE, otherwise approval has to be sought from a PCT’s exceptions committee. BCG is a live vaccine and must not be given to patients on immunosuppressant therapy. Where this is in place and a patient is stable, monitoring may then be accepted by primary care. poor absorption), regular or dispersible forms should be tried. If required to continue diclofenac, halve its dosage. Biologics Live vaccines should not be given to patients receiving treatment with biologics (refer to table 1). Indications: (Licensed) RA and Wilson’s disease B. The only exceptions are acrolimus, ciclosporin and t methotrexate/leflunomide combinations – where extended monthly monitoring longer term is advocated. Clinical response should be carefully assessed, including DAS 28 score, at 3 and 6 months. However the immunological response may be inadequate and a repeat dose should be considered at three months if the response titre is low. It is used, but not yet licensed, for the treatment of active juvenile Stills disease or active RA when anti-TNF and/or Rituximab have failed. (Nb During pregnancy doses of prednisolone 20mg daily or greater can lead to neonatal addisonian crisis) Immuno-suppression can lead to serious consequences with infections and live vaccines. Immunisation with the oral cholera vaccine (Dukoral®) does not provide complete protection. 1090 0 obj <>/Filter/FlateDecode/ID[<11C4673FC283284093061D3E238E7F14><0B74B0954AF4954CAE03AE9DED152259>]/Index[1083 15]/Info 1082 0 R/Length 62/Prev 295826/Root 1084 0 R/Size 1098/Type/XRef/W[1 3 1]>>stream For people on any disease-modifying anti-rheumatic drug (DMARD), consider stopping treatment and referring urgently to rheumatology if monitoring results show any of the following: White cell count less than 3.5 x 10 9 /L. Then monthly for 3 months. The guideline includes 74 recommendations: 23% are strong and 77% are conditional. June 2017. Clinicians should consider . Shared Care Guidelines are local policies to enable GPs to pick up the prescribing and monitoring of medicines/treatments in primary care in agreement with the initiating specialist. Full clinical reassessment of response at weeks 12 and 24, with treatment withdrawal if response inadequate (reduction in DAS 28 < 1.2 or overall DAS 28 >3.2). Folic acid 5mg daily or weekly, except on the day of the MTX, should be used to reduce toxicity. If injection site reaction try topical (or oral) anti-histamine / corticosteroids. Leeds has had more experience of this agent in clinical practice than anywhere else in the UK. Adequate resuscitation facilities must be immediately available. Consultant Rheumatologists are also contactable by telephone, fax or email for advice when needed. Malaria prophylaxis is essential when travelling to countries where there is a risk of developing malaria. Dose Typical dose 7.5mg-25mg once weekly. Paracetamol oral 1g 4–6 hourly (maximum 4g in 24 hours) 1. 1,2 Spontaneous remission is uncommon (<5%) and most affected individuals require long term disease modifying anti-rheumatic drug (DMARD) therapy to control symptoms and prevent joint damage. The final new agent to be covered in this edition is tocilizumab. h�bbd```b``��u �Q ,�D����B������L�,��*q����� ` ]o � ROUTINE TESTING Baseline BP and Creatinine Clearance FBC / U&E / LFT / Lipids Repeat FBC / U&E / LFT and BP At week one 2 weekly for 2 months (0-2 months) Monthly for 4 months (2 to 6 months) Then 3 monthly +/- Lipids IF WCC < 3.5 Neutrophils < 2.0 Platelets < 150 AST or ALT > 3 times normal range Abdominal pain / Diarrhoea / Rash / Bruising / Bleeding Stop medication and contact local Rheumatology service If unsure or progressive abnormal trend telephone/fax D PENICILLAMINE (4 / 3 / 2009) When commencing treatment the following will be considered 1) Avoid in pregnancy and breastfeeding 2) Known renal or hepatic impairment 3) Caution if ANA positive (check) 4) Caution if previous reaction to chrysotherapy 5) Potential drug interactions : - renal toxicity with NSAIDS - zinc and iron may reduce absorption so avoid either within 2 hours of dosing Treatment is usually started at 125mg daily taken at least half an hour before food/milk or last thing at night. Contraindicated in pregnancy and breast- feeding. Unlike rituximab, it is felt abatacept can be used equally in seronegative patients. A responsible GP has been identified for each patient. 2) Known hypertension / renal / hepatic impairment /malignancy 3) There are many potential drug interactions: always check with pharmacy / BNF. DMARD MONITORING GUIDELINES – FOR GP INFORMATION 10.10.08 Azathioprine A. Immunosuppressed patients may be given non-live vaccines (refer to table 2). WCC < 3.5 Neutrophils < 2.0 Pruritis / Rash Contact local Rheumatology service INFLIXIMAB (see anti-TNF) (5 / 3 / 2009) This is a human / murine monoclonal antibody given by IV infusion usually at 3 or 5mg/kg given at 0, 2 and 6 weeks initially and 2 monthly thereafter. The dose is calculated using body weight. Initial assessment of patients and the decision to start treatment will continue to be carefully made by Consultants and GPs where appropriate. They now have NICE approval for psoriasis, psoriatic arthritis and (with the exception of infliximab) for ankylosing spondylitis. Recommended DMARD Blood Monitoring Schedule when Starting or Adding a New DMARD Check FBC, creatinine/calculated GFR, ALT and/or AST and albumin every 2 weeks until on stable dose for 6 weeks; then once on stable dose, monthly FBC, creatinine/calculated GFR, ALT and/or AST and albumin for 3 months; thereafter, FBC, creatinine/calculated GFR, ALT and/or AST and albumin at least … Previous. Biologic therapies are not without potential risk, and hence it is important that clinicians are aware of these risks and ensure that appropriate precautions are taken to minimize t… BAD: Dermatologists generally do not use this drug. Where possible patients should be treated as part of regional studies / protocols and prospective data collected. Scrupulous attention to food, water, and personal hygiene is essential when travelling to areas where cholera exists. No specific laboratory monitoring is required during TNF inhibitor therapy as haematological and liver test abnormalities are rarely caused by these agents. The monitoring parameters cited are derived from a range of guideline sources, other reference sources and expert opinion and must therefore be considered suggestions only. monitoring non-biological disease-modifying antirheumatic drugs (DMARDs) for patients with rheumatic disease. This is increased on a bd dosage regimen by 500mg each week, if tolerated, up to a dose of 1.0 or 1.5grams bd (optimum around 40mg/kg/day). High risk patients (e.g. The guideline includes 74 recommendations: 23% are strong and 77% are conditional. Go to algorithm. Also prescribed for Psoriatic Arthritis, Crohns disease, connective tissue disease (SLE, myositis and vasculitis), Felty’s syndrome. Use - Aciclovir / Ganciclovir contraception for 6/52 after - Azathioprine discontinuation. If unsure or progressive abnormal trend telephone/fax BIOLOGIC THERAPY (5 / 3 / 2009) Immunotherapy of autoimmune disease in rheumatology and other specialties has changed enormously in the last decade. Dose: Grade of evidence: C Typical dose is: RA: 10–20 mg once a day [1–3] when monotherapy is used. Its use is extending to other conditions where B cells, or auto antibodies, play an important role in pathogenesis. Scenario: General principles of managing DMARDs: covers the general principles of managing an adult who is on a DMARD. Unfortunately NICE did not approve of this treatment (on the basis of cost), so experience outside Leeds is limited and unlikely to expand as quickly. ROUTINE TESTING Baseline : FBC / U + E / LFT Consider Hep B & C Repeat FBC/LFT : 2 weekly for 2 months (0-2 months) : monthly for 4 months (2-6 months) : Then 3 monthly (assuming dose stable) IF WCC < 3.5 Neutrophils < 2.0 Platelets < 150 AST or ALT > 3 times normal range Mouth or Throat Ulceration Unexplained bruising or bleeding Fever / Nausea / Vomiting / Diarrhoea Diffuse alopecia Stop medication and contact local Rheumatology service. endstream endobj startxref This is felt to reduce toxicity, particularly to the bladder. If unsure or progressive abnormal trend telephone/fax SULFASALAZINE EC (4 / 3 / 2009) When commencing treatment the following will be considered : 1) Age / Sex of patient 6) Potential drug interactions - Advise safe in pregnancy+folate 5mg daily - Digoxin - Cause of reversible oligospermia (reduced absorption) 2) Renal or Hepatic impairment - Azathioprine can 3) Soft Contact lens wearers (staining) increase marrow 4) Caution if ANA positive (check) toxicity 5) Previous Sulphonamide reactions Treatment is usually started at a dose of 500mg EC after food in the evening. Quick Reference Guide – Ongoing Monitoring Requirements for Disease Modifying Anti-rheumatic Drugs (DMARDs) Rachael Pugh, Prescribing Adviser & Abigail Cowan, Prescribing Advisers, Medicines Management Team, MLCSU Written: March 2016 Approved: MCGT June 2016 Review date: June 2019 DMARD FBC U&Es/serum creatinine LFTs Other BP CKS recommends following the recommendations of local guidelines. Trials are continuing in this condition, but also more widely in RA. The British Society of Rheumatology advises the following: “Clinicians may need to be flexible about blood testing for patients on stable DMARDs. Full clinical reassessment of response at week 12 and 24, with treatment withdrawal if response inadequate (reduction in DAS 28 < 1.2 or overall DAS 28 >3.2). Rheumatology Department DMARD Monitoring Guidelines for Methotrexate Indications Licenced for RA and Psoriasis. ROUTINE TESTING when treatment commences Baseline BP FBC / U&E and LFT Repeat Week 2 = BP and FBC / LFT Then 2 weekly for 2 months (0-2) Monthly for 4 months (2-6) Then 3 monthly (stable dose) IF WCC < 3.5 Neutrophils < 2.0 Platelets < 150 AST or ALT > 3 times normal range Significant BP rise or > 160/95 Abdominal pain / Nausea / Diarrhoea / Weight loss Pruritis / Rash / Breathlessness Stop medication and contact local Rheumatology service If unsure or progressive abnormal trend telephone/fax IF needed washout = cholestyramine 8gr tds 11 days METHOTREXATE (4 / 3 / 2009) When commencing treatment the following should be considered : 1) Age/Sex & alcohol intake 5) All should stop 3/12 before 2) Contraindicated in pregnancy considering conception and when breastfeeding 6) Potential drug interactions : 3) Renal or Hepatic impairment - NSAIDS eg diclofenac, salicylate 4) Underlying chest disease/smoker - Other anti-folates (eg phenytoin - All patients with RA should trimethoprim, cotrimoxazole) have a pre-treatment CXR - Uricosurics and PFT. Treatment is by IV infusion at week 0, 2 and 4 weeks and then on a 4 weekly basis. Evidence for combination with alternative appropriate DMARD’s is poor. They largely reflect the BSR core guidelines for DMARD monitoring, except that these have no information on biologic agents. rheumatoid arthritis; DMARDs (biologic) DMARDs (synthetic) treatment; economic evaluations; The European League Against Rheumatism (EULAR) developed its first recommendations for the management of rheumatoid arthritis (RA) with synthetic and biological disease-modifying antirheumatic drugs (DMARDs) in 2010.1 They summarised the state of the art and provided rheumatologists, … (Unlicensed) Vasculitides, such as polyarteritis and giant cell arteritis [1] and systemic lupus These Yorkshire Guidelines are felt … Frequency of injections can be reduced according to response to once every 4 - 8 weeks. Our guidelines grow out of the collaborative efforts of many members and non-members, specialists and generalists, patients and carers. hޜ�kkA���|o���� j��~hBR���E�*�)��{fVS����8�s�y���Jh��0��� Where possible previous TB contact, but no active infection, etanercept may be the preferred choice. Also prescribed for Psoriatic Arthritis, Crohns disease, connective tissue disease (SLE, myositis and vasculitis), Felty’s syndrome. Treatment is given as an IV infusion at 8mg/kg, initially 2 weekly and then at 4 weekly intervals. PAGE 26 PAGE 2 $ . This can occur in primary care when supported by the national Directed Enhanced Service or a local Enhanced Service. Background Shared care guidelines are used by hospitals and primary care for drug toxicity monitoring in the UK. There has been recent BSR safety guidance (2016 and 2017) on the use of biologics, which has been incorporated. Pneumococcal vaccine should be given 2-4 weeks before starting a biologic as response after starting treatment is thought to be poor. It is licenced and approved by NICE for uncontrolled active RA, AS, JIA, Psoriasis and PsA (see website). Prophylaxis is not absolute and personal protection against being bitten is very important. In some patients response can be late but significant and maintained. Table 1 lists the current live vaccines available in the UK: Table 1, Live vaccines VaccineBrand NameBCGBacillus Calmette-Guerin VaccineMeasles, Mumps and Rubella Combined Vaccine (MMR)MMRvaxPRO®, Priorix®Poliomyeltis (Live oral vaccine)Poliomyeltis Vaccine, live (oral) GSK OPVRotavirus (Live oral vaccine)Rotarix®Typhoid (Live oral vaccine)Vivotif®Varicella-Zoster VaccineVarilrix®, Varivax®Yellow Fever Arilvax®, Stamaril® If vaccination is required with a live preparation it should not be given until 3 months after the above listed drugs have been stopped or 2 to 4 weeks prior to commencing the medication (see below).

How To Draw Stuffing, Lamb's Ear Varieties, Multiplex Pcr Vs Real-time Pcrinstacart Developer Api, Big Kids Jungle Moc Frosty Waterproof, Specialized Fuse Bottom Bracket, Taylor Hawkins Net Worth 2020, Black Gold Soil Near Me, Syamel Dan Ernie Bercinta, 6 Ft Poseable Skeleton,