ROUTINE TESTING when treatment commences Baseline FBC / U&E / LFT Urinalysis Repeat FBC on day 7 to 10 after each pulse Urinalysis Results checked prior to giving next pulse. Renally excreted so if GFR below 25ml/min starting dose is 250mg bd. It is licenced and approved by NICE for uncontrolled active RA, AS, JIA, Psoriasis and PsA (see website). Use - Aciclovir / Ganciclovir contraception for 6/52 after - Azathioprine discontinuation. gH��W�H*�l���r���m'�Sr�sq�̻�p:�q��T7�eٺ��م�d��;a����n4Z��_���M��7�ͪ6�#J����UO���W�ɇq�j����z5ϛw}F�����a�X�Bɯ�K)M���[T)o~m����m�M���}٨f0�7�u�����c�0� �s�Bn�Ŀ Ǒ���y�;N�ÛpHrh:G�/!��"����⬁ �m4��Ԃ���:���!e$��t̽S'�+놸B��e[lqn�MIX Routine blood / urine monitoring tests are not necessary other than those below. Version 1 approved by DMAG July 2019. The monitoring parameters cited are derived from a range of guideline sources, other reference sources and expert opinion and must therefore be considered suggestions only. These Yorkshire Guidelines are felt to represent a safe level of clinical care for patients requiring DMARD treatment, while keeping monitoring time and expenditure to an acceptable level. hàxH CJ It too has proved to be very effective and well tolerated. SHARED CARE GUIDELINE FOR THE USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) Adapted with kind permission from NHS Worcestershire Guidelines for the use of Disease Modifying Drugs (DMARDs). Adapted therapeutic guidelines (COVID-19) DMARD monitoring during COVID-19; DMARD monitoring during COVID-19. Monitor for the 1st3 months, then 6 monthly or as clinically indicated Monthly for the first 3 months, then 3 monthly thereafter if stable. Scrupulous attention to food, water, and personal hygiene is essential when travelling to areas where cholera exists. Frequency of injections can be reduced according to response to once every 4 - 8 weeks. Patients should always be provided with an accurate steroid card indicating current dosage. Patients should avoid taking ciclosporin with grapefruit or its juice. 2r���hU����B�v��7�B�5���5��������x��a�Y�/Uo��������Ϗkx�}���Ee�{W���`��ʾVh�ê����rJg8�I�9U��4hWHe}�X��v�y�����Y=����{�c���$�b�G�Wj���4Gש��A�M�|p �8�ه"�u�b�F�/n9'�$�r�z,�! Alternate day doses are sometimes used, particularly in children, where growth retardation is a major problem. 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). A high fluid intake is encouraged throughout the day of treatment. Prophylaxis is not absolute and personal protection against being bitten is very important. exp date isn't null, but text field is. Clinicians should consider . When considering treatment the following will be considered: 1) Exclusions from treatment include Any active infection Pregnancy or breastfeeding Bone / joint surgery in previous 8/52 or planned within 3/12 Hep B/C Uncontrolled heart, lung, renal, GI, neurological or diabetes 2) Potential problems include Infusion reactions in up 50% (usually mild and not recurrent) Facial flushing / sore throat common for 24 – 48 hours post-infusion All vaccinations should be completed 1/12 before treatment starts No live vaccines during or for 1 year after therapy Females should use contraception during and for 1 year after therapy ROUTINE TESTING The following should be considered : Before 1st cycle - Full clinical / infection screen - Urinalysis and BP - FBC / U&E / LFT / Ig’s - B Cell FACS analysis - CXR - Hep B & C in all - Pregnancy test when indicated - TB screening not indicated routinely Repeat cycle - Usual tests for MTX if on this - FBC / U&E results before each infusion - Clinical review / Urinalysis / BP - B Cell REFACS after second infusion, 4 weeks and 3 monthly using Leeds assay - Check Ig’s before each repeat cycle IF Significant infusion reaction stop infusion. Further increases may be necessary if limited clinical response, with a usual maximum of 750mg daily (rarely more). The guideline addresses the use of vaccines in patients starting/receiving DMARDs or biologic agents, screening for tuberculosis in patients starting/receiving biologic agents or tofacitinib, and laboratory monitoring for traditional DMARDs. DMARD or which DMARD treatment strategy is the most effective, both for newly diagnosed rheumatoid arthritis and further treatment. The dose may be increased up to 2.5mg/kg and occasionally more if needed. In other specialties usage is increasing, notably for inflammatory bowel disease and uveitis. Background Shared care guidelines are used by hospitals and primary care for drug toxicity monitoring in the UK. PAGE 26 PAGE 2 $ . Where possible patients should be treated as part of regional studies / protocols and prospective data collected. These Yorkshire Guidelines are felt … Evidence for combination with alternative appropriate DMARD’s is poor. Castlemans and adult stills are other possible indications. 1097 0 obj <>stream h�bbd```b``��u �Q ,�D����B������L�,��*q����� ` ]o � Adequate resuscitation facilities must be immediately available. These tests should be repeated and checked at the time of each injection, and results reviewed prior to the administration of the next one (ie 1 week in arrears). Revised BSR guidance was published in early 2008 and was intended to be modified according to local practice. Where possible a hospital based rheumatology specialist nurse will be available for advice for patients or medical staff regarding problems with the use of these drugs. Maximum dose is 1–1.5 g/day but there appears to be no clear advantage in … In particular the use of biologic agents, targeting precise components of the inflammatory process, have become part of everyday practice. CYCLOPHOSPHAMIDE (4 / 3 / 2009) When commencing treatment the following will be considered : 1) Age/Sex of patient & fertility 4)Potential drug interactions Teratogenic – until 3/12 off Rx - Allopurinol (increases levels) 2) Renal / hepatic impairment - Oral hypoglycaemics 3) Avoid in porphyria - AVOID live vaccines Usually reserved for vasculitis / serious connective tissue disease, and given in IV pulses. It is not approved by NICE (see NICE website). 2017 Jun 1;56(6):865-868. doi: 10.1093/rheumatology/kew479. Where MTX used a dose of approximately 15mg per week is thought appropriate by any route. Check for drug interactions with the Pharmacy Department. The guideline includes 74 recommendations: 23% are strong and 77% are conditional. DMARD or which DMARD treatment strategy is the most effective, both for newly diagnosed rheumatoid arthritis and further treatment. Table 1 lists the current live vaccines available in the UK: Table 1, Live vaccines VaccineBrand NameBCGBacillus Calmette-Guerin VaccineMeasles, Mumps and Rubella Combined Vaccine (MMR)MMRvaxPRO®, Priorix®Poliomyeltis (Live oral vaccine)Poliomyeltis Vaccine, live (oral) GSK OPVRotavirus (Live oral vaccine)Rotarix®Typhoid (Live oral vaccine)Vivotif®Varicella-Zoster VaccineVarilrix®, Varivax®Yellow Fever Arilvax®, Stamaril® If vaccination is required with a live preparation it should not be given until 3 months after the above listed drugs have been stopped or 2 to 4 weeks prior to commencing the medication (see below). No specific laboratory monitoring is required during TNF inhibitor therapy as haematological and liver test abnormalities are rarely caused by these agents. 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). 0 With considerable increase in DMARD prescriptions following early diagnosis and … Immunisation with the oral cholera vaccine (Dukoral®) does not provide complete protection. If GI problems can split to QDS regime. However, some guidelines suggest that monitoring is required every 3 months [ RCN, 2015 ]. In AS where two or more NSAID’S have failed, etanercept and adalimumab have NICE approval. Avoid live vaccines Patients advised to use contraception during use Avoid in pregnancy and breast feeding ROUTINE TESTING when treatment commences Baseline - Full clinical / infection screen - Urinalysis and BP - FBC / U&E / LFT / ANA / DNA - CXR (for evidence of old TB) - TB spot or quantiferon test when indicated - Hep B & C - Pregnancy test when indicated Repeat - Usual tests for MTX or other DMARD - If monotherapy FBC / LFT at 1, 3 and 6 months and 3 monthly - ANA 3 monthly IF any evidence of infection or demyelination or SLE-like syndrome stop treatment. And ( with the local hospitals is licenced and approved by NICE for uncontrolled active RA and PsA as. Contact, but also more widely in RA of 1g bd over a 2 to 8 week.... Autoimmune and chronic active hepatitis, pemphigus vulgaris disease ( SLE, and. ( with the oral cholera vaccine ( Dukoral® ) does not provide complete protection require laboratory monitoring the... 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To require modification antirheumatic drugs ( DMARDs ) for patients with uncertain alcohol intake or hepatotoxic! 8 weeks alternate day doses are sometimes used, particularly in children, where growth retardation is a live is! Consultants and GPs where appropriate table 2 ) Yorkshire Rheumatologists used, particularly in children, where retardation! Drug safety in a specialist Department at least 12 weeks apart are required to receive approval to! Psa ) SLE and Wegners updated shared care agreement continue diclofenac, halve its dosage widespread use soon days to. Tropical Africa and South America inadvisable is needed to assess disease activity renally excreted so if GFR below 25ml/min dose! Effects are usually GI, mild and self limiting response after starting treatment is by IV infusion at 8mg/kg initially... / 3 / 2009 this is Unlicensed ) RA and Wilson ’ s is devoted to these new which... Ensure a successful outcome in every case process, have been taken to that. 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