This latest guidance sets out evidence based recommendations for clinicians prescribing synthetic, non-biologic, anti-rheumatic drugs to tackle multisystem rheumatic conditions. Previous guidelines on DMARDs were published in 2008 but significant shifts in the evidence base mean updated guidance is needed. Monitoring of DMARDs is essential and the guideline includes focuses on baseline screening; implications of co-morbid illness; monitoring for toxicity; management during intercurrent illness or surgery, and shared care guidance.
The guidelines are accredited by the National Institute for Health and Care Excellence (NICE) which recognises robust, evidence-based and critically evaluated high-quality processes applied to developing a clinical guideline.
Significant changes from the 2008 document include:
- Harmonisation of monitoring schedules, recommending that all DMARDs that require laboratory monitoring follow the same frequency of testing (fortnightly until on a stable dose for 6 weeks, then monthly until 6 months, then quarterly thereafter). The only exceptions are Tacrolimus, Ciclosporin and Methotrexate/Leflunomide combinations – where extended monthly monitoring beyond six months is advocated.
- More nuanced discussion of the use of methotrexate in lung disease is provided, drawing from the two large meta-analyses recently published. Background lung disease should not be considered an absolute contraindication to methotrexate use, although in patients with poor respiratory reserve (in whom an acute pneumonitis would be more hazardous), caution is advised.
- Significant change is made regarding the evaluation of retinal toxicity for hydroxychloroquine users: Patients should have baseline screening (ideally including Optical Coherence Tomography (OCT)) within the first year of commencing therapy, and then enrol into annual OCT assessments after 5 years of use. The change reflects the current evidence base which demonstrates that simple in-clinic tests (e.g. the Amsler Grid) only identify retinopathy once irreversible damage has already occurred. OCT enables near histological level imaging of the retinal, and enables detection of early HCQ related changes before significant damage has occurred, enabling prevention of visual loss. OCT is now widely available (it is the screening tool used to detect macular degeneration), however the guideline acknowledges the significant burden that this recommendation will have upon NHS resources and is actively working with the Royal College of Ophthalmology to provide more detailed guidance on this specific topic in the future.
Commenting on the updated guidance, lead author Dr James Galloway, Senior Clinical Lecturer at King’s College London said:
These updates have two major focuses: firstly, streamlining monitoring schedules wherever possible, given the myriad of different regimens across drugs, and most of the schedule variations were somewhat arbitrary in their origins; second, to review and incorporate the evidence base available, acknowledging several key publications that have emerged since the first guidance. The update provides an accessible and useful tool for primary and secondary care prescribers of anti-rheumatic therapies.
Dr Elizabeth Macphie, the Chair of the Standards, Audit and Guidelines Working Group at the British Society for Rheumatology echoed this:
The society is committed to providing knowledge and tools to its members to enable them to deliver up to date, evidence-based patient care. These new guidelines will be invaluable for UK practitioners in prescribing and will make a direct, and positive, impact to their clinical practice. I’ll be using them myself.