Review of Routine Laboratory Monitoring for Patients with Rheumatoid Arthritis Receiving Biologic or Nonbiologic DMARDs

Table 1

Laboratory monitoring guidelines for DMARDs in patients with RA.

	Lipids	Liver enzymes (function, ALT, and AST)	Neutrophils and/or platelets	Serum creatinine	Ref(s)
Conventional synthetic DMARDs
Methotrexate	N/A	LFT every 1-2 months	CBC with differential and platelet counts at least monthly	N/A	PI [29]
	N/A	ALT 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 thereafter	CBC 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 thereafter	At baseline, every 2–4 weeks for the first 3 months, every 8–12 weeks the following 3–6 months, and every 12 weeks thereafter	ACR [16]
	N/A	ALT and/or AST every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	Full blood count every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	Creatinine/calculated GFR every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	BSR [17, 18]
Leflunomide	N/A	ALT levels ≥ monthly for 6 months after initiation; every 6–8 weeks thereafter	Platelet count, white blood cell count, and hemoglobin or hematocrit monitored at baseline and monthly for 6 months after initiation and every 6–8 weeks thereafter	N/A	PI [30]
	N/A	ALT 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 thereafter	CBC 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 thereafter	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 thereafter	ACR [16]
	N/A	ALT and/or AST every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	Full blood count every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	Creatinine/calculated GFR every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	BSR [17, 18]
HCQ/CQ	N/A	ALT and AST at baseline and none thereafter	CBC at baseline and none thereafter	At baseline	ACR [16, 73]
Gold	N/A	ALT and/or AST every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	Full blood count every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	Creatinine/calculated GFR every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	BSR [17, 18]
Sulfasalazine	N/A	LFT at baseline and every 2 weeks during the first 3 months, monthly during the second 3 months, and every 3 months or as needed thereafter	CBC 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 thereafter	N/A	PI [74]
	N/A	ALT 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 thereafter	CBC 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 thereafter	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 thereafter	ACR [16]
	N/A	ALT and/or AST every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	Full blood count every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	Creatinine/calculated GFR every 2 weeks until stable dose for 6 weeks, then monthly for 3 months; at least every 12 weeks thereafter	BSR [17, 18]
Biologic DMARDs
	N/A	N/A	N/A	N/A
	N/A	Same as for	Same as for	Same as for
	N/A	N/A	N/A	N/A
	N/A	Same as for	Same as for	Same as for
	N/A	N/A	N/A	N/A
Tocilizumab	4–8 weeks after initiation and every 24 weeks thereafter	ALT and AST levels 4–8 weeks after initiation and every 3 months thereafter	ANC 4–8 weeks after initiation and every 3 months thereafter	N/A	PI [75]
	N/A	Same as for	CBC and platelet counts at 2- and 4-month intervals during rituximab therapy	N/A	PI [33]
	None required	None required	N/A	N/A	PI [76]
	N/A	N/A	N/A	N/A
Targeted small-molecule DMARDs
Tofacitinib	4–8 weeks after initiation	Routine monitoring of all	At initiation, 4–8 weeks after initiation, and every 3 months thereafter	N/A	PI [32]
Glucocorticoids	At baseline, 1 month after initiation, and every 6–12 months thereafter				Liu 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.