Table 1: Laboratory monitoring guidelines for DMARDs in patients with RA.

LipidsLiver enzymes (function, ALT, and AST)Neutrophils and/or plateletsSerum creatinineRef(s)

Conventional synthetic DMARDs

MethotrexateN/ALFT every 1-2 monthsCBC with differential and platelet counts at least monthlyN/API [29]
N/AALT and AST at baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks the following 3–6 months, and every 12 weeks thereafterCBC at baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks for 3–6 months after initiation, and every 12 weeks thereafterAt baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks the following 3–6 months, and every 12 weeks thereafterACR [16]
N/AALT and/or AST every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterFull blood count every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterCreatinine/calculated GFR every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterBSR [17, 18]

LeflunomideN/AALT levels ≥ monthly for 6 months after initiation; every 6–8 weeks thereafterPlatelet count, white blood cell count, and hemoglobin or hematocrit monitored at baseline and monthly for 6 months after initiation and every 6–8 weeks thereafterN/API [30]
N/AALT and AST at baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks for 3–6 months after initiation, and every 12 weeks thereafterCBC at baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks for 3–6 months after initiation, and every 12 weeks thereafterAt baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks for 3–6 months after initiation, and every 12 weeks thereafterACR [16]
N/AALT and/or AST every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterFull blood count every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterCreatinine/calculated GFR every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterBSR [17, 18]

HCQ/CQN/AALT and AST at baseline and none thereafterCBC at baseline and none thereafterAt baselineACR [16, 73]

GoldN/AALT and/or AST every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterFull blood count every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterCreatinine/calculated GFR every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterBSR [17, 18]

SulfasalazineN/ALFT at baseline and every 2 weeks during the first 3 months, monthly during the second 3 months, and every 3 months or as needed thereafterCBC with differential at baseline and every 2 weeks during the first 3 months, monthly during the second 3 months, and every 3 months or as needed thereafterN/API [74]
N/AALT and AST at baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks for 3–6 months after initiation, and every 12 weeks thereafterCBC at baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks for 3–6 months after initiation, and every 12 weeks thereafterAt baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks for 3–6 months after initiation, and every 12 weeks thereafterACR [16]
N/AALT and/or AST every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterFull blood count every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterCreatinine/calculated GFR every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafterBSR [17, 18]

Biologic DMARDs

N/AN/AN/AN/A

N/ASame as for Same as for Same as for

N/AN/AN/AN/A

N/ASame as for Same as for Same as for

N/AN/AN/AN/A

Tocilizumab4–8 weeks after initiation and every 24 weeks thereafterALT and AST levels 4–8 weeks after initiation and every 3 months thereafterANC 4–8 weeks after initiation and every 3 months thereafterN/API [75]

N/ASame as for CBC and platelet counts at 2- and 4-month intervals during rituximab therapyN/API [33]

None requiredNone requiredN/AN/API [76]

N/AN/AN/AN/A

Targeted small-molecule DMARDs

Tofacitinib4–8 weeks after initiationRoutine monitoring of allAt initiation, 4–8 weeks after initiation, and every 3 months thereafterN/API [32]

GlucocorticoidsAt baseline, 1 month after initiation, and every 6–12 months thereafterLiu et al. [41]

ACR, American College of Rheumatology; ALT, alanine aminotransferase; AST, aspartate aminotransferase; BSR, British Society for Rheumatology; CBC, complete blood count; DMARD, disease-modifying antirheumatic drug; HCQ/CQ, hydroxychloroquine/chloroquine; LFT, liver function test; MTX, methotrexate; N/A, not available; PI, prescribing information; RA, rheumatoid arthritis; ref, reference. , infliximab, etanercept, golimumab, certolizumab, abatacept, and anakinra do not currently have a laboratory monitoring program; patients receiving these medications should follow the laboratory monitoring guidelines for any coadministered medications. , golimumab, and rituximab are indicated for RA only in combination with methotrexate. -associated toxicity is dependent on lifetime cumulative dose and average daily dose. the time of this review, monitoring guidelines for baricitinib and sarilumab have not been established.