DMARD monitoring: a practical guide
Baseline tests, blood-monitoring schedules, when to withhold, and screening before biologics and JAK inhibitors — on one page.
Before starting any conventional DMARD
- Full blood count, creatinine/eGFR, ALT and/or AST, albumin
- Hepatitis B (HBsAg, anti-HBc), hepatitis C and HIV serology
- Chest X-ray (and TB screening before biologics / JAK inhibitors — IGRA or Mantoux)
- Pregnancy plans and contraception discussed; height, weight and blood pressure
- Vaccinations reviewed — vaccine guidance
Monitoring schedule (methotrexate, leflunomide, azathioprine, mycophenolate, sulfasalazine)
| Phase | Bloods (FBC, creatinine/eGFR, ALT/AST, albumin) |
|---|---|
| Starting or after a dose increase | Every 2 weeks until on a stable dose for 6 weeks |
| Next 3 months | Monthly |
| Thereafter | At least every 12 weeks |
- After a dose increase, return to 2-weekly tests for 6 weeks (many clinicians use monthly checks for small increments — local practice).
- Leflunomide: also check blood pressure and weight at each visit.
- Methotrexate with leflunomide in combination: monthly monitoring continues indefinitely.
- Sulfasalazine: after 12 months on a stable dose with normal results, routine blood monitoring is no longer needed.
- Hydroxychloroquine: no routine blood monitoring. Annual retinal screening after 5 years of use, or after 1 year if there are risk factors (dose >5 mg/kg/day actual body weight, eGFR <60, tamoxifen). The AAO additionally suggests a baseline examination within the first year.
Ledingham J, Gullick N, Irving K, et al. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs. Rheumatology 2017;56:865–8. Hydroxychloroquine retinal screening: Royal College of Ophthalmologists 2020.
When to withhold and discuss
| Result | Action |
|---|---|
| WBC < 3.5 × 10⁹/L | Withhold until discussed with the specialist team |
| Neutrophils < 1.6 × 10⁹/L | Withhold until discussed |
| Platelets < 140 × 10⁹/L | Withhold until discussed |
| Lymphocytes < 0.5 × 10⁹/L | Withhold until discussed |
| Eosinophils > 0.5 × 10⁹/L | Withhold until discussed |
| ALT or AST > 100 U/L | Withhold until discussed |
| Unexplained fall in albumin < 30 g/L | Withhold until discussed |
| MCV > 105 fL | Check B12, folate and TSH; treat if low |
| Unexplained eGFR fall to < 60, or creatinine rise >30% over 12 months | Withhold until discussed |
Also act on trends — a consistent downward drift in counts, or a rising ALT within the normal range, deserves a closer look even before a threshold is crossed. New mouth ulcers, unexplained bruising, a sore throat or breathlessness on methotrexate warrant urgent blood tests and review.
Thresholds as per BSR/BHPR 2017.
Biologics and JAK inhibitors
- Screen for latent TB (IGRA or Mantoux plus chest X-ray), hepatitis B and C before starting; treat latent TB per national guidelines before or alongside starting.
- Hold during significant infection; restart when recovered.
- JAK inhibitors: FBC, LFTs and lipids at baseline and periodically; consider VTE, cardiovascular and malignancy risk factors, particularly age ≥65, smokers and those with cardiovascular risk. Recombinant zoster vaccination is worth considering.
- Tocilizumab: neutrophils, platelets, LFTs and lipids periodically.
- Rituximab: immunoglobulins at baseline and before repeat cycles.
Sick-day and peri-operative rules
- Fever or acute infection: hold methotrexate, leflunomide, biologics and JAK inhibitors until recovered.
- Surgery: methotrexate is usually continued; biologics are typically scheduled so surgery falls at the end of a dosing interval, and restarted after wound healing (no infection). JAK inhibitors are held about 3 days before surgery.
- Steroid-treated patients: continue the usual daily glucocorticoid dose; routine supraphysiological stress-dose cover is not recommended.
Peri-operative points per the 2022 ACR/AAHKS guideline for patients undergoing elective total hip or knee arthroplasty.
Referring a patient?
Walk-in rheumatology OPD at AIMS Mohali — no appointment needed. A short note with recent results helps the patient get the most from the visit.
Clinic timings & location