Recommended Monitoring Strategies For Drug Treatment of Rheumatoid Arthritis

			Monitoring
Drugs	Toxicities requiring monitoring[dagger]	Baseline evaluation	System review/examination	Laboratory

Salicylates, nonsteroidal antiinflammatory drugs	Gastrointestinal ulceration and bleeding	CBC, creatinine, AST, ALT	Dark/black stool, dyspepsia, nausea/vomiting, abdominal pain, edema, shortness of breath	CBC yearly, LFTs, creatinine testing may be required[Ddagger]
Hydroxychloroquine	Macular damage	None unless patient is over age 40 or has previous eye disease	Visual changes, funduscopic and visual fields every 6-12 months	-
Sulfasalazine	Myelosuppression	CBC, and AST or ALT in patients at risk, G6PD	Symptoms of myelosuppression[section], photosensitivity, rash	CBC every 2-4 weeks for first 3 months, then every 3 months
Methotrexate	Myelosuppression, hepatic fibrosis, cirrhosis, pulmonary infiltrates or fibrosis	CBC, chest radiography within past year, hepatitis B and C serology in high-risk patients, AST or ALT, albumin, alkaline phosphatase, and creatinine	Symptoms of myelosuppression[section], shortness of breath, nausea/vomiting, lymph node swelling	CBC, platelet count, AST, albumin, creatinine every 4-8 weeks
Gold, intramuscular	Myelosuppression, proteinuria	CBC, platelet count, creatinine, urine dipstick for protein	Symptoms of myelosuppression[section], edema, rash, oral ulcers, diarrhea	CBC, platelet count, urine dipstick every 1-2 weeks for first 20 weeks, then at the time of each (or every other) injection
Gold, oral	Myelosuppression, proteinuria	CBC, platelet count, urine dipstick for protein	Symptoms of myelosuppression[section], edema, rash, diarrhea	CBC, platelet count, urine dipstick for protein every 4-12 weeks
D-penicillamine	Myelosuppression, proteinuria	CBC, platelet count, creatinine, urine dipstick for protein	Symptoms of myelosuppression[section], edema, rash	CBC, urine dipstick for protein every 2 weeks until dosage stable, then every 1-3 months
Azathioprine	Myelosuppression, hepatotoxicity, lymphoproliferative disorders	CBC, platelet count, creatinine, AST or ALT	Symptoms of myelosuppression[section]	CBC and platelet count every 1-2 weeks with changes in dosage, and every 1-3 months thereafter
Corticosteroids (oral <=10 mg of prednisone or equivalent)	Hypertension, hyperglycemia	BP, chemistry panel, bone densitometry in high-risk patients	BP at each visit, polyuria, polydipsia, edema, shortness of breath, visual changes, weight gain	Urinalysis for glucose yearly
Agents for refractory RA or severe extraarticular complications
Cyclophosphamide	Myelosuppression, myeloproliferative disorders, malignancy, hemorrhagic cystitis	CBC, platelet count, urinalysis, creatinine, AST or ALT	Symptoms of myelosuppression[section], hematuria	CBC and platelet count every 1-2 weeks with changes in dosage, and every 1-3 months thereafter, urinalysis and urine cytology every 6-12 months after cessation
Chlorambucil	Myelosuppression, myeloproliferative disorders, malignancy	CBC, urinalysis, creatinine, AST or ALT	Symptoms of myelosuppression [section]	CBC and platelet count every 1-2 weeks with changes in dosage, and every 1-3 months thereafter
Cyclosporin A	Renal insufficiency, anemia, hypertension	CBC, creatinine, uric acid, LFTs, BP	Edema, BP every 2 weeks until dosage stable, then monthly	Creatinine every 2 weeks until dose is stable, then monthly; periodic CBC, potassium, and LFTs
* CBC = complete blood cell count (hematocrit, hemoglobin, white blood cell count) including differential cell and platelet counts; ALT = alanine aminotransferase; AST = aspartate aminotransferase; LFTs = liver function tests; BP = blood pressure. [dagger] Potential serious toxicities that may be detected by monitoring before they have become clinically apparent or harmful to the patient. This list mentions toxicities that occur frequently enough to justify monitoring. Patients with comorbidity, concurrent medications, and other specific risk factors may need further studies to monitor for specific toxicity. [Ddagger] Package insert for diclofenac (Voltaren) recommends that AST and ALT be monitored within the first 8 weeks of treatment and periodically thereafter. Monitoring of serum creatinine should be performed weekly for at least 3 weeks in patients receiving concomitant angiotensin-converting enzyme inhibitors or diuretics. [section] Symptoms of myelosuppression include fever, symptoms of infection, easily bruisability, and bleeding.