Careful monitoring of disease activity and adverse effects related to multiple medication use is essential.
Laboratory monitoring
Hepatitis B and C status, purified protein derivative (PPD), full blood count (FBC), and liver function tests (LFTs) need to be checked before starting disease-modifying antirheumatic drugs (DMARDs). Laboratory monitoring for FBC and LFT abnormalities is done every 4-8 weeks at the start of treatment. When the patient is on a stable dose, they should be checked every 3-4 months.[193]Yazici Y, Erkan D, Paget SA. Monitoring by rheumatologists for methotrexate-, etanercept-, infliximab-, and anakinra-associated adverse events. Arthritis Rheum. 2003 Oct;48(10):2769-72.
http://www.ncbi.nlm.nih.gov/pubmed/14558081?tool=bestpractice.com
[194]Yazici Y, Erkan D, Paget SA. Monitoring methotrexate hepatic toxicity in rheumatoid arthritis: is it time to update the guidelines? J Rheumatol. 2002 Aug;29(8):1586-9.
http://www.ncbi.nlm.nih.gov/pubmed/12180713?tool=bestpractice.com
Disease activity and response to therapy
Monitored by any of the composite scores available. These include the disease activity score (DAS) and its derivatives, health assessment questionnaire (HAQ) and its derivatives, routine assessment patient index data (RAPID3), simplified disease activity index (SDAI), and clinical disease activity index (CDAI).[185]Pincus T, Chung C, Segurado OG, et al. An index of patient reported outcomes (PRO-Index) discriminates effectively between active and control treatment in 4 clinical trials of adalimumab in rheumatoid arthritis. J Rheumatol. 2006 Nov;33(11):2146-52.
http://www.ncbi.nlm.nih.gov/pubmed/17080518?tool=bestpractice.com
[186]Pincus T, Sokka T. Complexities in the quantitative assessment of patients with rheumatic diseases in clinical trials and clinical care. Clin Exp Rheumatol. 2005 Sep-Oct;23(5 Suppl 39):S1-9.
http://www.ncbi.nlm.nih.gov/pubmed/16273778?tool=bestpractice.com
[187]Aletaha D, Smolen JS. The Simplified Disease Activity Index (SDAI) and Clinical Disease Activity Index (CDAI) to monitor patients in standard clinical care. Best Pract Res Clin Rheumatol. 2007 Aug;21(4):663-75.
http://www.ncbi.nlm.nih.gov/pubmed/17678828?tool=bestpractice.com
However, these scores are not commonly used in routine care and are one of the important aspects of management that needs to improve in routine rheumatology care.
The American College of Rheumatology (ACR) Working Group has recommended the following scores for measuring disease activity in rheumatoid arthritis patients: the 28-joint count version of DAS (DAS28), CDAI, SDAI, patient activity scale (PAS), and RAPID3. These scores appear to perform similarly in RA patients.[66]Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012 May;64(5):640-7.
https://onlinelibrary.wiley.com/doi/full/10.1002/acr.21649
http://www.ncbi.nlm.nih.gov/pubmed/22473918?tool=bestpractice.com