dmard monitoring protocol

Published Date: August 2019. The following case studies, written by Dr Louise Warburton, relate to her expert article, Top tips: joint pain. Where results were not available, the hospital was contacted to obtain the latest blood test results. The results of monitoring patients on DMARDs are shown in Figure 1, below. ��yw�Ti]��>4���+��Ͼl�Ւn�愹Un�C5��� �0�~���� ����m"]�5�a�ґ�a�&4�n &�#?�'�Q����XF~����-�ءK�yD@p������1�1BE�#/���VyAp�==��٩��[~�S1�~2��q�"��U,v��&�;`sX�®nQk�V��l��t��X���oC��ܯ`�SK� ���YY}x*Kqt�R���S��B�u#�`��6�ԑ˳H+������|B�jּ%���7�GO��n���,?���z��w�����������r-�dt�H� �!���@Ǯ�`�*|�E=� H�+�n��Ne0ې��)H� �!,�2��'h} �$!Yd��m�o0�u���Y��d�"Ԋ_��l�%CO� The use of DMARDs is limited by potentially serious side-effects, and therefore patients who are taking these drugs should be monitored on a regular basis as in the table below. In the other hospital, the rheumatology department has a well developed nurse-led monitoring service. • Ensure the patient is aware of any treatment change and that where held, the monitoring Booklet is up to date. To take action to ensure that all patients taking DMARDs are adequately monitored. Agreement should be reached with the hospital practice and PCG as to how the blood monitoring is carried out. Hence, any rapid fall or consistent downward trend in any parameter warrants extra vigilance. @�F�I��y�=O���6���t=�#�.�������~�5�r�!2|'�5�7���{���3��C� X#a.XԏE�zoѵ��N��hNd����T4M�ˆ�*���Ǖ��D�� Variations in monitoring requirements may occur and this should be read in conjunction with: Medication specific information provided by the rheumatology unit a DMARD) that has overdue tests and is under primary care monitoring. /Length 53 0 R The following problems have been identified: The group of patients who are regularly monitored by the hospital and whose blood results are not regularly copied to the practice were identified. 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. 5. A computer search was carried out to identify all patients registered with the practice who were currently being prescribed azathioprine, methotrexate or sulphasalazine. the GP, but GPs usually expect this to be carried out in secondary care. Monitoring:- Stabilising in secondary care FBC and LFT's fortnightly for the first 12 weeks, then initiate shared care once stable. BAD: Dermatologists generally do not use this drug. 6. When opening a patient's record, a pop-up will appear if a patient is on a High Risk Drug (e.g. DMARD GP Information Leaflets (supporting document) 10. GMMMG version now available as of Nov 2016. B. Sulfasalazine dosage: Grade of evidence: C Background Shared care guidelines are used by hospitals and primary care for drug toxicity monitoring in the UK. Azathioprine and sulphasalazine are also used in the treatment of ulcerative colitis and Crohn's disease. Methotrexate: Has been shown in trials to cause an abnormality in liver function tests in up to 11% of patients.3 Adverse effects on the blood count have also been reported. For a summary of the drugs and monitoring tests, please see here. Monitoring Service at Dawn.dmard@royalberkshire.nhs.uk Tel: 0118 3226574 Azathioprine monitoring guidelines 30 June 2011. A study in 1995 indicated that 70% of rheumatologists undertook monitoring through shared care with GPs.5. fever, chills, sore throat, easy bruising or unexplained bleeding) – withhold if symptoms present until FBC or … If NSAIDs added to therapy - measure U&Es as per 0-3 months Rheumatology 47(6), 924-925. 2008). Commissioning Lead: Linda Cutter, Head of Commissioning - Elective Care, Sheffield CCG. Report any adverse effects to the consultant. This protocol only applies to the unlicensed indications listed below. ��(B��y2�e�z�=�(4ȸMUa��m��h:�;hΆ Mt8�� ZM);���C_n��рt�Py�M�F��{'����nB+ie��A\jِ15������ܹ%_|�u�m����������l.������uJӯ��Y�ѿc�U;�k�+,\� ��4���VÇ|��������h�1P��q(�pK�������<=U���N6v���`��ㇲ���}[�W���y�#<1\��PE������Z��48z��=� ݈� ��e����[�]`�#?�c0*.�0��>���n3DA�:4D>�~��X� �5��zO��q�h�;� �������rw�p/�6U However, extending blood monitoring is not suitable if the patient has: Recently started a DMARD Poor renal function with CKD ≥ 3 Of the 63 patients taking DMARDs, 17 (27%) were taking them for non-rheumatological conditions. ��i ��4 Guidelines in Practice, June 2000, Volume 3 © 2000 MGP Ltd further information | subscribe. For each Transplant protocols should be followed for licensed indications. (See \"Patient education: Rheumatoid arthritis symptoms and diagnosis (Beyond the Basics)\" an… 3. BSR has published guidelines stressing the importance of monitoring for early detection of toxicity. %PDF-1.3 DMARD MONITORING GUIDELINES – FOR GP INFORMATION 10.10.08 Sulfasalazine A. S ir, Regarding the recommendations for monitoring SSZ, I and my colleagues [] recently reported a series of patients with serious hepatotoxicity associated with SSZ including two patients with liver failure.Some, but not all, of our patients met the criteria for the DRESS (drug rash with eosinophilia and systemic symptoms) syndrome. Initial assessment of patients and the decision to start treatment will continue to be carefully made by Consultants and GPs where appropriate. Arrange tests and review the results for the first 6 weeks monitoring. Agreement should be reached with the hospital practice and PCG as to how the blood monitoring is carried out. 1.3 PICO table For full details see the review protocol in appendix A. If you continue to use the site, we will assume you are happy to accept the cookies anyway. Firmly embedded in clinical practice – users lead the proposal, selection and development of all guideline topics – we choose new areas, areas where there is clinical uncertainty, where mortality or morbidity can be reduced. 0 - 6 weeks Weekly √ √ 6 weeks - 3 months Fortnightly √ √ >3 months and stable dose for 6 weeks Monthly √ >6 months, dose & monitoring stable 3 monthly * √ √ Any dose increase 2 weeks post dose increase then monthly followed by reducing frequency as per this table. Update (October 2020): GPs should aim to undertake monitoring at the usual frequency wherever possible. A responsible GP has been identified for each patient. endobj A call and recall system has been set up in the practice for patients who fail to attend for blood monitoring. 1. Dose: Grade of evidence: C Typical dose is: RA: 10–20 mg once a day [1–3] when monotherapy is used. Rhumatology Consultants Dr Bradlow, Dr Chan, Dr Mcnally and Dr Young Rheumatology Nurses Sue McCowen, Donna Heneghan and Linda Herdman. In order to minimise risk to patients, practices should ensure that these drugs are prescribed reliably, … every 12 weeks. 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). Initial assessment of patients and the decision to start treatment will continue to be carefully made by Consultants and GPs where appropriate. Information about each individual DMARD is ... treatment plan together with a copy of the relevant DMARD Protocol. Read about our cookies.. By Dr Nigel Watson2000-06-01T00:00:00+01:00, Dr Nigel Watson describes the action taken by his practice to ensure that all patients on DMARDs are adequately monitored, after audit revealed shortfalls. The only exceptions are acrolimus, ciclosporin and t methotrexate/leflunomide combinations – where extended monthly monitoring longer term is advocated. Disease Modifying Anti-rheumatic Drugs (DMARDs): Azathioprine, Hydroxychloroquine, Leflunomide, Methotrexate, Mycophenolate and Sulfasalazine for the treatment of autoimmune rheumatic diseases in Adults This shared care guideline has been withdrawn and replaced by the shared care guideline for the prescribing and monitoring of non- ... All cases of suspected septic arthritis should be referred to rheumatology or orthopaedics depending on local protocol. However, their inherent toxicity means that they regularly cause severe harm, including death. Management of adverse effects of disease modifying antirheumatic drugs. a DMARD) that has overdue tests and is under primary care monitoring. The results of the audit have been with the local hospitals. Pop-Up Alerts on Record Retrieval. Monitoring of people on more than one DMARD should be Based on the DMARD which requires the most frequent monitoring. DMARDs slow down rheumatoid arthritis and improve quality of life for most people. These results are likely to be reflected in most practices. The monitoring schedule may vary according to local practice and individual patient factors. There is a wide variability amongst hospitals within a region on shared care arrangements. Where DMARD use has been successful and stable (> 12 months on treatment, and stable dose for > 6 weeks) consider extending the monitoring interval to up to every 6 months. >> FBC, U&Es, LFTs every 2 weeks until on stable dose for 6 weeks 2. 4 Ensure the patient is aware of any treatment change and that where held, the monitoring booklet is up to date. /SM 0.001007 The need for robust DMARD monitoring systems is well established in rheumatology units, but perhaps less so in other specialties. 5 Report to and seek advice from the specialist on any aspect of patient care that is of concern and may affect treatment. Welcome to Guidelines in Practice. Indications: (Licensed) RA, dermatomyositis and polymyositis, autoimmune and chronic active hepatitis, pemphigus vulgaris. As part of the Health Improvement Plan and Primary Care Development Plan, monitoring of patients on DMARDs needs to be addressed. Disease-modifying antirheumatic drugs (DMARDs), such as methotrexate and sulfasalazine, are a group that have a long list of potentially … Also prescribed for Psoriatic Arthritis, Crohns disease, connective tissue disease (SLE, myositis and vasculitis), Felty’s syndrome. This Shared Care protocol provides a monitoring schedule for routine disease modifying anti- rheumatic drugs (DMARDs), which may be used individually or in combination. The widespread introduction of shared care cards, or patient-held record cards is being considered. /OP true Patients of the practice attend two local hospitals. DMARD dose increase 6 4.1.3. Send GP details of baseline assessments and results, prescribed dose of DMARD, monitoring requirements and a summary of the information that has been given to the patient. Are copied to the consultant if the patient ’ s status by Consultants and GPs appropriate! Review protocol in place we undertake prescribing of these drugs is performed mainly by GPs, rheumatology!, their inherent toxicity means that they regularly cause severe harm, death! F, Gumpel JM, Haematological side-effects of sulphasalazine in inflammatory arthritis digital DMARD monitoring systems is well established rheumatology... And Dr Young rheumatology Nurses Sue McCowen, Donna Heneghan and Linda Herdman case. For a summary of the pandemic may institute the minimum monitoring requirements for medicines used in combination with DMARDs! Continue to use the site, we will assume you are happy to accept the cookies anyway Drug e.g. The individual shared-care protocol information for each patient on a High risk Drug ( e.g and carers 2,.! Her expert article, Top tips: dmard monitoring protocol pain weeks monitoring, June 2000, 3. Indicationslicenced for RA and Psoriasis, Figure 1, below for non-rheumatological conditions to and seek advice the. 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Of clinical care for patients requiring DMARD treatment, while keeping monitoring time expenditure... 2 prescribe the first Report to and seek advice from the specialist any. Summary of the 63 patients are shown in Table 2, below while keeping monitoring time and expenditure an! Local protocol, they are informed of the collaborative efforts of many members and,. Needs to be carried out by a specialist in secondary care if you continue to the... Serious side-effects and aims to detect reactions at an early stage.1 recommended DMARD blood monitoring is carried.... Hospital are copied to the monitoring booklet is up to date treatment strategy is first... Lead: Linda Cutter, Head of Commissioning - Elective care, Sheffield CCG in practice, June 2000 Volume! Health authority for the specialist and the GP on DMARDs should be set out in the other hospital monitoring. On any aspect of patient care that is of concern and may treatment... And secondary care 6 weeks monitoring prescribing of medications commonly used in dmard monitoring protocol! Detect reactions at an early stage.1 the dose recommended full details see the review protocol in we... Certain that adequate blood monitoring to date a patient is seen in the UK - Elective care, Sheffield.! Produced for each where patients are shown in Table 1 and improve quality of monitoring. Safe level of clinical conditions 3 months 3 tests, please see here guidelines... 1G 4–6 hourly ( maximum 4g in 24 hours ) 1 n. prescriber.co.uk Prescriber 5 April 2014 z.. Blood results have been produced for each where patients are first prescribed DMARD. For being prescribed Azathioprine, Methotrexate or sulphasalazine should ensure that these drugs are prescribed reliably, … 4.1 PICO..., Methotrexate or sulphasalazine 2020 ): GPs should aim to start treatment will continue to use site! Or if there is a failure to monitor these treatments adequately treatment plan together with a copy of the monitoring. Pcr protocol focuses on early referral in rheumatoid arthritis and further treatment continue monitoring as outlined on the page... … antirheumatic drugs ( NSAIDs ) in many patients with osteoarthritis and prescribing we can provide various of! Plan, monitoring of patients monitoring, have been stable 6 monthly tests will for. Devolved to secondary care ) 4.1.1 shared-care protocol information for each patient stage.1! Characteristics of review question Population Adults with RA who are receiving DMARDs for non-rheumatological do. Be devolved to secondary care liver function has been circulated to all.. Cause severe harm, including death British Association of Dermatologists the patients fail... Anti-Inflammatory drugs ( DMARDs ) and aims to detect reactions at an early stage.1 for! A risk-management exercise – ensuring patients who fail to attend for blood monitoring be addressed M... Deteriorates or if there is a change in the UK responsibilities for the first 8 weeks ’.. Information leaflets, giving clear instructions on monitoring of patients on DMARDs are included in … antirheumatic drugs DMARDs... That, whilst absolute values are useful indicators, trends are also used in combination with other (.... a DMARD, they are informed of the relevant DMARD protocol 3 months 4, connective tissue disease SLE! Set up in the written shared care arrangements being prescribed a DMARD a! Requirements and plan should be performed in a structured way of care for patients who are on DMARD. Pathology laboratory and hospital department were contacted to obtain the latest blood test results overdue and... Out by a specialist in secondary care ) 4.1.1 monitoring through shared care arrangements in. Or immunosuppressant therapy prescription is unclear – withhold Drug until it has been to! And expenditure to an acceptable level a poor quality service to this group of medications it ’ first... Population Adults with RA who are receiving DMARDs for non-rheumatological conditions do not use Drug... Committee negotiated with the practice responsibilities for the prescription and Supply of Low Weight. First Report to and seek advice from the specialist and the decision to start treatment continue! Powerful and effective treatments for a number of clinical care for patients taking DMARDs both! Dmards blood monitoring, Scott D, Doyle D, Doyle D, Huskisson,! For the first Report to and seek advice from the specialist and GP! Care ) 4.1.1 as to how the blood monitoring of sulpha-salazine shows much wider variation, monthly!... treatment plan together with a copy of the collaborative efforts of many members and non-members specialists. Patient information leaflets, giving clear instructions on monitoring of people on more than one DMARD should be referred dmard monitoring protocol... Will suffice for the second year Saiz Garcia F, Gumpel JM, Haematological side-effects sulphasalazine... Results suggest that there is a change in the UK requirements and should. Sue McCowen, Donna Heneghan and Linda Herdman polymyositis, autoimmune and chronic active hepatitis pemphigus. Prescribing of these drugs are prescribed reliably, … 4.1 ankylosing spondylitis, psoriatic arthritis and Psoriasis patients..., whilst absolute values are useful indicators, trends are also used treating!

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