Adnan Saad, GP Principal, Sheepcot Medical Centre, Watford; Associate Professor, St George’s University, Grenada; and Clinical Tutor, Imperial College School of Medicine, London.
Kavyesh Vivek, third-year medical student (Medicine in Community Apprentices), Imperial College School of Medicine, London.
Jai Anand, third-year medical student (Medicine in Community Apprentices), Imperial College School of Medicine, London.
Disease-modifying drugs are important for reducing disease burden, improving quality of life, and reducing the time patients spend in hospital.1 However, a majority of such drugs can result in systemic damage,2 and so would require close monitoring and follow-up to avoid such drug-induced complications.
Much of the monitoring of commonly issued disease-monitoring drugs is done in general practice, and may carry both a clinical incentive for the patient, as well as a service and financial incentive for the practice. Despite best endeavours, the ability of successfully monitoring disease modifying drugs is still low3 and so has potential to further improve.
We therefore felt it would be useful to design an easy-to-use ‘crib sheet’ (see Box 1) that a clinician may readily reference to ensure that the correct investigations and timeframe for these investigations can be performed for each disease-monitoring drug. This crib sheet can be saved on a desktop, a smart phone file, or even printed off and stuck to a notice board or side of a clinician’s computer, making it a very easy reference tool.
| Box 1. A clinician’s crib sheet for common disease monitoring drugs4,5 | |||
| Medications | Frequency | Monitoring | Indications |
| Methotrexate | 3 monthly | FBC, U&Es, eGFR, LFTs, and weight | Crohn’s disease, RA, neoplasms, and psoriasis |
| Azathioprine | 3 monthly | FBC, U&Es, eGFR, LFTs, and weight | IBD, RA, SLE, connective tissue disorders, polymyositis, autoimmune conditions, transplantation rejection, refractory eczema, and myasthenia graves |
| Mercaptopurine | 3 monthly | FBC, U&Es, eGFR, LFTs, and weight | IBD, acute leukaemia, and CML |
| Mycophenolate | 3 monthly | FBC, U&Es, eGFR, LFTs, and weight | Acute transplantation tissue rejection prophylaxis |
| Sulfasalazine | 3 monthly for first year, annually U&Es and eGFR | FBC, U&Es, eGFR, LFTs, and weight | IBD and RA |
| Leflunomide | 3 monthly | FBC, U&Es, WBCC diff, eGFR, LFTs, weight, and BP | RA and psoriatic arthritis |
| Ciclosporin | 3 monthly | FBC, U&Es, eGFR, LFTs, weight, BP, glucose, and lipid profile | UC, RA, atopic dermatitis, psoriasis, graft-versus-host disease, nephrotic syndrome, and keratitis |
| Hydroxychloroquine | Annually | Ophthalmological examination | SLE, DLE, RA, and sunlight-related dermatological conditions |
| BP = blood pressure. CML = chronic myeloid leukaemia. DLE = discoid lupus erythematous. eGFR = estimated glomerular filtration rate. FBC = full blood count. IBD = irritable bowel disease. LFT = liver function test. RA = rheumatoid arthritis. SLE = systemic lupus erythematous. U&E = urine creatinine. UC = ulcerative colitis. WBCC = white blood cell count. | |||
References
1. Fries JF, Williams CA, Morfeld D, et al. Reduction in long-term disability in patients with rheumatoid arthritis by disease-modifying antirheumatic drug-based treatment strategies. Arthritis Rheum 1996; 39(4): 616–622.
2. Wang W, Zhou H, Liu L. Side effects of methotrexate therapy for rheumatoid arthritis: a systematic review. Eur J Med Chem 2018; 158: 502–516.
3. Byng-Maddick R, Wijendra M, Penn H. Primary care attitudes to methotrexate monitoring. Qual Prim Care 2012; 20(6): 443–447.
4. National Institute for Health and Care Excellence. British National Formulary. 2023. https://bnf.nice.org.uk (accessed 24 Feb 2023).
5. Specialist Pharmacy Service. Medicines monitoring. 2021. https://www.sps.nhs.uk/home/tools/drug-monitoring (accessed 24 Feb 2023).
Featured photo by Diana Polekhina on Unsplash.
