Monitoring
To monitor for drug
toxicity, complete blood count, serum creatinine, liver function tests,
hepatitis B and C screening, ophthalmologic exam, latent TB screening (for
bDMARDs, with chest X-ray) are requested. It is recommended to monitor patients
for drug toxicity due to the potential risks of serious adverse effects prior
to resuming or increasing therapy with DMARDs. Treatment is
monitored every 2-4 weeks for rheumatoid arthritis therapy of <3 months and
every 8-12 weeks for therapy of 3-6 months.
Prior to tapering of
therapy, patients should have a low disease activity or be in remission for at
least 6 months. A dose reduction (decrease in dose or increase in the dosing
interval) is recommended over gradual discontinuation of a DMARD along with a
close evaluation of patients during any tapering of therapy. Patients in
persistent remission for 12 months can consider
tapering bDMARD or tsDMARD therapy, especially in
combination with csDMARD, after tapering glucocorticoid therapy. Gradual tapering of csDMARD treatment may also be considered
after discontinuing bDMARD or tsDMARD therapy.
Flare risk is inversely
proportional to disease activity and sustained response duration, thus, to
decrease the risk of flares, cautious tapering and
gradual withdrawal of biological therapies should be done. As discontinuation
of therapy is associated with a high risk of flares, careful reduction of dose
or increase in the interval can be done with all bDMARDs and tsDMARDs with a little
risk of flares. Most patients who flare can regain their prior good response
upon prompt re-institution of the same bDMARD or tsDMARD therapy. Ceasing
treatment with csDMARDs is associated with increased flare frequency, hence
tapering should be done cautiously and should be evaluated rigorously.
Disease activity should be measured, documented, and monitored regularly.
- Active disease: Every 1-3 months
- Sustained low disease activity or remission: Monitoring may be performed less frequently (eg every 6 months)
- If there is no improvement within 3 months of treatment initiation or the treatment target has not been achieved within 6 months, therapy should be adjusted
Disease activity monitoring includes clinical assessment (especially joint counts), lab tests for markers of inflammation (eg CRP), and patient-reported information. Complications of rheumatoid arthritis are assessed (eg infection, CV disease, osteoporosis, malignancy) and additional examinations are performed as indicated. Consider structural changes, comorbidities, and functional impairment when formulating treatment decisions on follow-ups.
Prognosis
Poor prognostic factors in patients with rheumatoid arthritis include a high count of swollen joints, evidence of early erosions, the presence of rheumatoid factor and/or anti-citrullinated protein antibody (particularly at high levels), high levels of acute phase reactants, moderate or high disease activity persisting despite treatment with csDMARDs based on composite measures including joint count, treatment failure with ≥2 csDMARDs, and other factors such as female gender, older age, smoking history, and presence of obesity or anemia.