Before starting

Required

• Baseline
  • Albumin
  • ALT or AST
  • Blood pressure
  • Full blood count · to include differential white cell count and platelet count
  • Height
  • Weight
  • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate

Consider

• Baseline
  • Screening for lung disease

Consider in patients at risk of infection

• Baseline
  • Hepatitis B
  • Hepatitis C
  • HIV

After started or dose changed

Required

• Every 2 weeks until on stable dose for 6 weeks, then monthly for 3 months
  • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate
  • Full blood count
  • ALT or AST
  • Albumin

Consider increasing frequency

Consider increasing frequency of testing for patients at higher risk of toxicity.

Ongoing once stable

Required

• At least every 12 weeks for first 12 months
  • Albumin
  • ALT or AST
  • Full blood count
  • Serum creatinine (for creatinine clearance) or Calculated glomerular filtration rate

Consider

• Annually
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate

Consider increasing frequency

Consider increasing frequency of testing for patients at higher risk of toxicity.

Abnormal results

Respond to absolute values

Stop treatment and contact consultant if 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 greater than 0.5 x 10⁹/L
• Platelets less than 140 x 10⁹/L
• Albumin less than 30g/L (or unexplained fall)
• MCV greater than 105f/L

Liver function

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

Renal function

• Creatinine increase greater than 30% above baseline over 12 months
• Calculated GFR less than 60ml/min/1.73m²

Respond to patient symptoms

Stop treatment and discuss with consultant if any of the following develop.

• Rash or itch
• Hair loss
• Severe sore throat/oral ulceration or abnormal bruising/bleeding (check FBC immediately)
• Breathlessness or dry cough
• GI upset (nausea, vomiting or diarrhoea)
• Weight loss
• Peripheral neuropathy

Notes

Advice to patients

Advise patients to report any of the following:

• unexplained bleeding
• bruising
• rash
• sore throat
• fever
• malaise

Advise contact lens wearers that some soft contact lenses may get stained with treatment.

Beware of blood dyscrasia or toxicity

Perform a full blood count and stop treatment immediately if a blood dyscrasia or toxicity is suspected.

Bibliography

• Ledingham J, Gullick N, Irving K et al. BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs, Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868 [cited 21/02/2020)
• Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press [cited 21/02/2020]
• Pfizer Limited. Summary of Product Characteristics – Salazopyrin Tablets. Last revised 10/2019 [cited 04/02/2020]
• NICE Clinical Knowledge Summaries (CKS). DMARDs. Updated Jul 2018 [cited 21/02/2020]
• Lamb CA, Kennedy NA, Raine T et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019; 68:s1-s106 [cited 30/07/2020]