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. 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). Not used in Psoriasis. Clinical response should be carefully assessed, including DAS 28 score, at 3 and 6 months. DMARD MONITORING GUIDELINES – FOR GP INFORMATION 10.10.08 D-Penicillamine A. Tests for patients on disease-modifying arthritis drugs. Also prescribed for Psoriatic Arthritis, Crohns disease, connective tissue disease (SLE, myositis and vasculitis), Felty’s syndrome. Initial assessment of patients and the decision to start treatment will continue to be carefully made by Consultants and GPs where appropriate. Patients should always be provided with an accurate steroid card indicating current dosage. A responsible GP has been identified for each patient. Reliable contraception essential until drug elimination completed (In both men and women - see SPC – though risk small) 3) Renal or Hepatic impairment (contraindicated in hepatitis B/C carriers) 4) Potential drug interactions : - Cholestyramine / Rifampicin / Warfarin / Tolbutamide - AVOID Live vaccines Do not use loading dose of 100mg daily for three days. Treatment is given as an IV infusion at 8mg/kg, initially 2 weekly and then at 4 weekly intervals. Maximum dose is 1–1.5 g/day but there appears to be no clear advantage in … Steps have been taken to ensure that all blood tests performed by the hospital are copied to the practice. Where this is in place and a patient is stable, monitoring may then be accepted by primary care. Indications: (Licensed) RA and psoriatic arthritis (PsA). This section on DMARD’S is devoted to these new agents. It is licenced and approved by NICE for uncontrolled active RA, PsA, AS and in JIA (see website). Where TLCO less - Penicillin’s may potentiate than 70% or clinical concern levels of MTX an HRCT chest is advisable - Avoid Live vaccines Treatment may begin at a dose of 10- 15mg WEEKLY in 2.5mg tabs and increased to 20mg after 2 – 4 weeks. 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. Further increases may be necessary if limited clinical response, with a usual maximum of 750mg daily (rarely more). BCG is a live vaccine and must not be given to patients on immunosuppressant therapy. Patients prescribed a biologic (other than TCZ) without concomitant csDMARD (or with csDMARDs tha… FBC and urine should then be checked after 6 days prior to giving the next full dose of 50mg IM. IF WCC < 3.5 Neutrophils < 2.0 Platelets < 150 Oral Ulceration / Unusual Bruising / Rash / Fever Cough or Shortness of Breath / Nausea / Alopecia Urgent contact with local Rheumatology service If unsure or progressive abnormal trend telephone/fax IM GOLD (Myocrisin) (4 / 3 / 2009) When commencing treatment the following will be considered: 1) Avoid in pregnancy or when breastfeeding 2) Caution in elderly 3) Avoid if significant renal or hepatic impairment 4) Caution if known blood dyscrasia Baseline : FBC / U + E / LFT Urinalysis Consider baseline CXR This is usually started with a test dose of 10mg given by deep IM injection and the patient supervised for 20-30 minutes. Monitoring The guideline recommends a standard schedule for monitoring patients newly prescribed a DMARD or when a second DMARD is initiated (see Table 3) but again there are many exceptions. Conclusion A high fluid intake is encouraged throughout the day of treatment. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs Rheumatology (Oxford). Alternate day doses are sometimes used, particularly in children, where growth retardation is a major problem. Where MTX used a dose of approximately 15mg per week is thought appropriate by any route. Dose: Grade of evidence: C Typical dose is: RA: 10–20 mg once a day [1–3] when monotherapy is used. monitoring non-biological disease-modifying antirheumatic drugs (DMARDs) for patients with rheumatic disease. Our guidelines grow out of the collaborative efforts of many members and non-members, specialists and generalists, patients and carers. Consider dose reduction of paracetamol in patients with low body weight (≤50kg), renal / hepatic impairment or glutathione deficiency (chronic malnourishment, chronic alcoholism) to 15mg/kg/dose up to four times daily (max 60mg/kg/day). those at high risk of TB) should be reviewed every 3 months (grade 2C, SOA 94%). Combined Adsorbed diphtheria (low dose), tetanus and inactivated poliomyelitis preparation given. 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. If you receive a request to prescribe in the absence of a shared care guideline which you feel is inappropriate please complete an inappropriate request form. It has also been used in psoriasis, atopic dermatitis and autoimmune bullous dermatoses such as pemphigus. 1.3 PICO table For full details see the review protocol in appendix A. 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). Pneumococcal vaccine should preferably be given before starting therapy, but if not it should be repeated at 5 yearly intervals (rather than 10). 1) Absolute contraindications Pregnancy / Breastfeeding (though early data is reassuring) Active infection Open leg ulcers Previously infected prosthetic joint (unless completely removed) Septic arthritis in last year HIV or Hepatitis B carriers Previous malignancy within 10 years (except BCC) NYHA Grade 3 or more heart failure Any history of demyelinating disease 2) Relative contraindications Uncontrolled diabetes Pulmonary fibrosis Bronchiectasis (assess severity) PUVA therapy of >1000 Joules Hepatitis C (absolute if RNA +ve) History of TB or positive PPD test (isoniazid and pyridoxine one month before starting and for further 6 months) NYHA heart failure grade 1 or 2 3) Potential Problems Atypical or unusual infections Neutropenia / aplasia Pneumonitis / lung fibrosis Infusion / injection site reactions ANA or DNA positivity (especially infliximab) Induction of autoimmunity Interaction with anikinra AVOID Live Vaccines ( SEE VACCINES SECTION) ADALIMUMAB (see anti-TNF) (5 / 3 / 2009) This is a human monoclonal antibody given as a 40mg sub cut injection every 2 weeks. 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 > E l n v w x ” ˜ ™ š Ÿ § ¨ © ª ¼ ½ ¾ İ Ş ß à ÷ S ] ± Biologics Live vaccines should not be given to patients receiving treatment with biologics (refer to table 1). Thereafter, at least every 12 weeks. 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. Nausea, indigestion and headache are the most common problems. If unsure or progressive abnormal trend telephone/fax VACCINATIONS (5 / 3 / 2009) General information Live vaccinations should not be given to patients receiving Azathioprine, Methotrexate, Leflunomide, Ciclosporin, Cyclophosphamide and Biologics (Anti-TNF, Abatacept, Anakinra, Rituximab and Tocilizumab). This is felt to reduce toxicity, particularly to the bladder. A Regional protocol is currently being established for day case administration of IV pulse therapy. Paracetamol oral 1g 4–6 hourly (maximum 4g in 24 hours) 1. Rituximab, a monoclonal antibody which depletes B cells, has NICE approval for RA where anti-TNF agents have failed, and may be used for patients where they are contraindicated. Indications: (Licensed) RA and Wilson’s disease B. Dose Typical dose 7.5mg-25mg once weekly. N.B.Patients … 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. Thresholds for action remain unchanged. There is no contra-indication for the administration of live vaccines to relatives or friends of patients on immunosuppressant drugs. Malaria prophylaxis is essential when travelling to countries where there is a risk of developing malaria. Scenario: General principles of managing DMARDs: covers the general principles of managing an adult who is on a DMARD. 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