Disease-Modifying Anti-Rheumatic Drug (DMARD) dose, screening and monitoring requirements

Drug	Pre-treatment	Dose	Monitoring
Methotrexate	FBC, U&Es, LFTs, CXR in last 6/12	increase by 2.5mg every 2 weeks	FBC,U&Es, LFTs, 2 weekly until dose stable, then monthly
Leflunomide	FBC, U&Es, LFTs, BP	10-20mg	FBC, U&Es, LFTs, weekly for 6/52, then 2-4/52. Monitor BP
Sulfasalazine	FBC, U&Es, LFTs	500mg od 1/52, bd 1/52, 500mg + 1g 1/52, 1g bd	FBC, U&Es, LFTs monthly
Hydroxychloroquine	FBC, U&Es, LFTs	200-400mg od	Annual eye check
Azathioprine	FBC, U&Es, LFTs, TPMT	Start @ 1mg/kg/day, increase every 4-6/52 (target 2mg/kg/day)	FBC & LFTs weekly for 6/52, then 2 weekly until dose stable, then monthly
Mycophenolate	FBC, U&Es, LFTs, CXR in last 6/12	Start @500mg/day, increase by 500mg every week (max 3g/day)	Weekly until dose stable, then fortnightly for 2/12, then monthly

DMARDS in acutely unwell patients

If in doubt, stop them and liaise with rheumatology
Should always be stopped in septic patient and:
- Consider IV folinic acid for patients on methotrexate
- Consider washout with cholestyramine or activated charcoal for patients on leflunomide