The British Society for Rheumatology has published an updated evidence-based clinical guideline on the safe use of conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs) across the full spectrum of autoimmune rheumatic diseases.
Key recommendations:
- Following influenza or COVID-19 vaccination in adults, methotrexate should be withheld for up to two weeks, assuming disease activity / risk of flare allows. In the paediatric age group, this is up to the discretion of the clinician and an individualised approach is needed.
- Non-invasive scoring using a Fibrosis index (FIB-4) followed by an elastography (e.g. Fibroscan®) if indicated is recommended for adults with risk factors for liver disease when starting methotrexate, although this should not delay methotrexate initiation.
- During a severe infection, e.g. requiring intravenous therapy or hospitalisation, csDMARDs should be temporarily discontinued until the patient has recovered from the infection.
- Risk factors for DMARD toxicity should be reviewed at least annually, adjusting the frequency of monitoring according to the level of risk identified.
- The management of patients on csDMARD therapy should be a collaborative effort between primary care and specialist rheumatology providers. A shared care protocol should be agreed upon (including in the paediatric age group when shared care exists) delineating the responsibilities of each party.
Read the guideline here.