AB1609-HPR ADHERENCE WITH THE CURRENT GUIDELINES FOR THE MONITORING OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDs)
Authors: Z. Alkutobi, R. Daly-East, S. Zilahuma, A. Nandagudi
Journal: Annals of the Rheumatic Diseases (2024)

<h3>Background:</h3> Serious adverse effects can be associated with DMARDs including pancytopenia and hepatotoxicity. International guidelines for monitoring after initiating DMARDs recommended by NICE [1], BSR/BHPR [2] and ACR [3] are variably followed by different institutions. <h3>Objectives:</h3> This QIP aimed at reviewing adherence to the NICE/BSR guidelines; including blood monitoring of full blood count, liver and renal functions following DMARDs initiation at 2, 4, 6, 10, 14 and 18 weeks, followed by tri-monthly blood tests. <h3>Methods:</h3> We randomly selected 51 patients meeting inclusion criteria of being diagnosed with inflammatory arthritis and commenced on DMARDs over a period in twelve months in 2022-2023. Demographics, comorbidities, number of blood tests done were reviewed for 18 weeks post commencement and any adverse events followed by course of action were noted. Adherence was assigned only if the blood tests were conducted in full and within 6 days of the calculated required date. <h3>Results:</h3> Female to male ratio for our cohort was 1.93 with age range of 18-89 years. The diagnoses included Rheumatoid Arthritis in 68.3%, Psoriatic Arthritis in 26.8% and the remaining 4.9% were other forms of inflammatory arthritis. Osteoarthritis and Hypertension were the most common comorbidities at 17% for each followed by COPD, Asthma, and Hypothyroidism. The DMARDs commenced were Methotrexate for 68.3%, Sulfasalazine for 19.5% and Leflunomide for 12.2%. Clinicians distributed blood test forms to be done after 2, 4, and 6 weeks at initial consultations in 70.5% of the cases. The total number of the blood tests done for the patients included in the study was 246. None of the patients underwent full monitoring for 18 weeks but 92.8% underwent partial monitoring and 7.2% had no monitoring. The renal function was omitted in 93.8% as it was considered as non-essential requirement by some rheumatologists. The lowest compliance with full monitoring was 15.9% at week 4, whereas the highest rate of non-compliance was at weeks 14 and 10 at 61% and 58% respectively, please see Figure1. There was only one abnormality of low platelet count of 110 x 109/L two weeks after starting sulfasalazine and it was stopped. <h3>Conclusion:</h3> Whilst strict monitoring is crucial to ensure DMARDs safety, the complexity of the monitoring process is a barrier to compliance, among other factors including comorbidities, limitation of blood test appointments, patient's busy life and lack of adequate communication with the medical staff. Increasing adherence can be helped by distributing leaflets and date-labelled blood test request forms, stressing on gaining new skills for the staff at the primary service and ensuring open access to liaise with secondary care. There is a need for a pragmatic approach towards DMARDs monitoring balancing safety with real life evidence. <h3>REFERENCES:</h3> [1] Ledingham J, Gullick N, Irving K, Gorodkin R, Aris M, Burke J, Gordon P, Christidis D, Galloway S, Hayes E, Jeffries A. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs. Rheumatology. 2017 Jun 1;56(6):865-8. [2] https://cks.nice.org.uk/topics/dmards/management/monitoring-of-dmards/. [3] Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, Paulus HE, Mudano A, Pisu M, Elkins-Melton M, Outman R. American College of Rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis Care &amp; Research: Official Journal of the American College of Rheumatology. 2008 Jun 15;59(6):762-84. <h3>Acknowledgements:</h3> <b>NIL.</b> <h3>Disclosure of Interests:</h3> <b>None declared.</b>