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Using this page · Individualise medicines monitoring

This medicines monitoring page has been written using publications and expert opinion. It is designed to save clinician time, but not replace professional responsibility. When using this page you should: ensure an individualised monitoring plan is developed in partnership with the patient and take account of any locally agreed advice and guidance.

Before starting

Required

  • Baseline
    • Albumin
    • Blood pressure
    • Body weight
    • Chest x-ray or Screening for lung diseasephysical examination and lung function may also be necessary on case-by-case basis
    • Full blood count
    • Height
    • Hepatitis Bconsider antiviral treatment prior to initiation if chronic viral hepatitis
    • Hepatitis Cconsider antiviral treatment prior to initiation if chronic viral hepatitis
    • HIV
    • Liver function testsconsider delayed initiation if results abnormal
    • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rateavoid in severe renal impairment; reduce dose if moderate

Consider

  • Baseline
    • TB screeningif suspected TB; where positive, treat before initiating
    • Varicella Zoster Virus Immunityif no history of infection; vaccinate if low

Dermatology patients

  • Baseline
    • Type III Procollagen Peptide (PIIINP)if psoriasis

After started or dose changed

Required

  • Every 1 - 2 weeks
    • Full blood count
    • Liver function tests
    • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate

Dermatology patients

  • Every 1-2 weeks for first month; repeat until dose stabilised
    • Full blood count
    • Urea and electrolyes
    • Liver function tests

Gastroenterology patients

  • At 2, 4, 8, and 12 weeks; then 3 monthly
    • Full blood count
    • Liver function tests
    • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate

Rheumatology patients

  • Every 2 weeks for at least 6 weeks; then every month for 3-12 months
    • Albumin
    • ALT or AST
    • Full blood count
    • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate

Increasing monitoring frequency

More frequent monitoring is appropriate in patients:

  • at higher risk of toxicity
  • where methotrexate is combined with leflunomide; for these patients, continue monthly monitoring until stable for 12 months, then consider reduced frequency monitoring on an individual basis

Ongoing once stable

Required

  • Every 2 -3 months
    • Full blood count
    • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate
    • Urea and electrolyes

Dermatology patients

  • Every 2 -3 months
    • Full blood countconsider increasing frequency if high risk
    • Liver function testsconsider increasing frequency if high risk
    • Urea and electrolyesconsider increasing frequency if high risk
    • Type III Procollagen Peptide (PIIINP)if psoriasis; seek specialist advice if abnormal

Rheumatology patients

  • At least every 12 weeks
    • ALT or ASTconsider increasing frequency if high risk
    • Full blood countconsider increasing frequency if high risk
    • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rateconsider increasing frequency if high risk

Gastroenterology patients

  • At least every 12 weeks
    • Full blood count
    • Liver function tests
    • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate

Abnormal results

Be aware of trends in results (e.g. gradual decreases in white blood cells or albumin, or increasing liver enzymes). A downward trend of FBC and neutrophil count or an upward trend in liver transaminases could be a sign of toxicity, even if the absolute levels are normal.

Respond to absolute levels

Consider stopping treatment and contacting a specialist any of the following develop:

Full blood count

  • WCC less than 3.5 x 109/L
  • Neutrophils less than 1.6 x 109/L
  • Unexplained eosinophilia more than 0.5x 10 9/L
  • Platelets less than 140 x 109/L
  • Unexplained fall in serum albumin less than 30g/L
  • MCV greater than 105fL (check B12, folate, thyroid-stimulating hormone levels – if abnormal treat, if normal discuss with specialist team)

Liver function

  • AST and/or ALT greater than 100units/mL

Renal function

  • Creatinine increase greater than 30% above baseline over 12 months
  • Calculated GFR less than 60ml/min/1.73m2 (repeat in 1 week, if still more than 30% from baseline, withhold and discuss with specialist team)

Bibliography

Enquiries about this page

Contact us if you have any enquiries about the drug monitoring information on this page.