Basis for recommendation

These recommendations are based on the British Society for Rheumatology (BSR) Guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs [BSR, 2026], the Yorkshire Rheumatology Regional Guidelines for the monitoring of adult patients on conventional disease modifying drugs, biologic drugs and targeted synthetic drugs [Tran, 2019], the Barnsley Hospital NHS Foundation Trust DMARDs Shared care prescribing guidelines [Barnsley Hospital NHS Foundation Trust, 2024], the Herefordshire and Worcestershire Integrated Care System Shared Care Guidelines for the use of Disease-Modifying Anti-Rheumatic Drugs (DMARDs) [Herefordshire and Worcestershire Integrated Care System, 2026] , the British National Formulary (BNF) [BNF, 2026], the UKHSA Immunisation against infectious disease (Green Book) Chapter on Shingles [UKHSA, 2025], and what CKS considers good clinical practice.

Shared care

• DMARDs are prescribed and monitored in primary care according to individualised shared-care arrangements provided by the specialist(s) who initiated and initially managed the person's treatment. Local guidelines may also exist. Although this CKS topic provides general advice regarding DMARD monitoring based on guidance from the BSR [BSR, 2026], readers should be aware of the importance of adhering to perosnalised specialist recommendations and local protocols.

Vaccinations

• The advice to consider withholding methotrexate for two weeks following influenza and COVID-19 vaccinations is based on the BSR guideline, which cites evidence from several randomized controlled trials assessing whether temporarily stopping methotrexate improves the immune response to vaccines [BSR, 2026].
  • For influenza vaccination, three trials involving a total of 693 participants assessed different interruption strategies, including pausing treatment before vaccination and withholding it for up to four weeks afterwards.
  • A short, two‑week interruption after vaccination was found to enhance immunogenicity while maintaining an acceptable safety profile, with fewer disease flares than a four‑week interruption.
  • The evidence indicated that stopping methotrexate before vaccination is not required to improve vaccine response.
  • For COVID‑19 vaccination, trials involved a collective total of 639 participants with immune‑mediated inflammatory disease. These studies assessed a two‑week pause after the primary vaccine series and after subsequent booster doses.
  • The findings were consistent with those from the influenza studies.
  • Four weeks after receiving a booster dose, individuals who withheld methotrexate for two weeks demonstrated significantly higher antibody levels than those who continued treatment.
  • This enhanced response persisted for up to 26 weeks and was observed across different ages, disease types, and methotrexate doses. 
  • Any decision to interrupt methotrexate must balance the potential immunological benefit against the risk of disease flare. In the COVID‑19 vaccination trials, a greater number of flares occurred over the 12‑week follow‑up period in the groups that paused methotrexate.
• The information on shingles vaccination for people who are immunosuppressed derives from The Green Book [UKHSA, 2025], which states that 'From September 2025, Shingrix® should be offered to all severely immunosuppressed individuals aged 18 years and over (with no upper age limit)' and details that people taking DMARDs are included in the definition of severely immunosuppressed individuals. Accordingly, the BSR also advises shingles vaccination for people taking DMARDs [BSR, 2026].

How should I monitor a person using a conventional DMARD?

• Monitoring a person on a DMARD usually includes periodic measurement of full blood count (FBC), electrolytes, renal and liver function, and serum albumin as well as advising the person to self-monitor for signs and symptoms suggestive of toxicity or myelosuppression.
• Carry out ongoing monitoring in primary care as per the shared care arrangement. While treatment is being established and stabilised, monitoring will be carried out in secondary care.
• The British Society for Rheumatology recommends the following monitoring schedules for most conventional DMARDs. Testing frequency is largely based on the person's risk of DMARD toxicity, which should be determined by the prescribing specialist:
  • Low‑risk of DMARD toxicity — people with normal BMI, no comorbidities, and normal baseline blood tests.
    • Two weeks after commencing treatment, then monthly for 3 months, then after a further 3 months, then every 6 months.
    • Total tests in first year: 6 (Weeks 2, 6, 10, 14, then 26, then 50).
  • Medium‑risk of DMARD toxicity — people with elevated BMI, type 2 diabetes, or regular alcohol intake (up to 10 units/week), but normal baseline blood tests.
    • Two weeks after commencing treatment, then monthly for 6 months, then every 3 months.
    • Total tests in first year: 9 (Weeks 2, 6, 10, 14, 18, 22, then 26, 38, 50).
  • High‑risk of DMARD toxicity — people with multiple comorbidities, who are taking interacting medications (such as anticoagulants, anti‑seizure drugs), or have borderline renal function.
    • Two weeks after commencing treatment, then every two weeks for three months, then monthly.
    • Total tests in first year: 16 (Weeks 2, 4, 6, 8, 10, then 14, 18, 22, 26, 30, 34, 38, 42, 46, 50).
• For information on interpreting monitoring results, see the section on When to seek specialist advice.
• Be aware that additional monitoring required for specific conventional DMARDs includes:
  • Ciclosporin — monthly monitoring may be required longer term. Blood pressure and HbA1c should be measured every three months. Magnesium should be measured every six months.
  • Leflunomide — blood pressure and weight should be measured at each monitoring appointment.
  • Hydroxychloroquine — annual retinopathy monitoring is indicated after five years of HCQ treatment, as well as in people taking HCQ greater than 5 mg/kg, those with impaired renal function, or with other independent risk factors for retinopathy.
    • Ensure that the person has been offered/advised of the need for retinopathy monitoring.
  • Tacrolimus — monthly monitoring may be required longer term but may then be reduced to every two to three months once the disease and treatment are stable. Blood pressure and HbA1c should be measured every 3 months.

How should I monitor a person using a biologic  DMARD?

• Treatment will be initiated and stabilised by a specialist, with monitoring carried out in secondary care during this period.
  • If ongoing primary care monitoring is required, this should be clearly outlined in a shared-care arrangement.
• All people taking a biologic DMARD should be reviewed in a specialist department at least every 6 months.
  • People at higher risk of adverse effects (such as those at high risk of TB) should be reviewed every 3 months.
• People taking a biologic DMARD (except tocilizumab) should be offered routine monitoring blood tests (FBC, creatinine/calculated GFR, ALT and/or AST and albumin) every three to six months.
  
  • For people receiving primary care monitoring due to concurrent use of a conventional DMARD, additional testing may not be required. Seek specialist advice if uncertain.
• Biologics requiring additional blood tests include:
  
  • Tocilizumab — full blood count (FBC), liver function every 4 weeks.
  • Rituximab —  immunoglobulin levels (baseline and periodic).

How should I monitor a person using a synthetic targeted DMARD?

• Treatment will be initiated and stabilised by a specialist, with monitoring carried out in secondary care during this period.
  • If ongoing primary care monitoring is required, this should be clearly outlined in a shared-care arrangement.
• People using apremilast should be monitored for psychiatric symptoms (including depression, suicidal ideation and behaviour).
• People using a Janus kinase (JAK) inhibitor (abrocitinib, baricitinib, filgotinib, tofacitinib, or upadacitinib) should be offered blood tests (FBC, liver and renal function) every three months. Lipid profile should be checked after 12 weeks, then periodically.
  • Periodic skin examination is recommended in all people taking a JAK-I, particularly those at increased risk of skin cancer.

Basis for recommendation

These recommendations are based on the British Society for Rheumatology (BSR) biologic DMARD safety guidelines in inflammatory arthritis [Holroyd, 2018], and Guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs [BSR, 2026], the Yorkshire Rheumatology Regional Guidelines for the monitoring of adult patients on conventional disease modifying drugs, biologic drugs and targeted synthetic drugs [Tran, 2019], the British National Formulary (BNF) [BNF, 2026], and individual Summaries of Product Characteristics (SPCs).

Shared care

• DMARDs are prescribed and monitored in primary care according to individualised shared-care arrangements provided by the specialist(s) who started and initially managed the person's treatment. Local guidelines may also exist. Although this CKS topic provides general advice regarding DMARD monitoring based on guidance from the BSR [BSR, 2026], readers should be aware of the importance of adhering to personalised specialist recommendations and local protocols.

Conventional DMARD monitoring

• • The information on monitoring of conventional DMARDs is based on expert opinion in the BSR Guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs [BSR, 2026].
    • The BSR advises that most conventional DMARDs can be monitored similarly, with frequency of monitoring largely guided by the person's risk of DMARD toxicity.
    • The 2026 BSR recommendations advise less frequent monitoring than previous (2017) version of the guideline.
    • The guideline development group states that this is a more balanced approach that maintains patient safety while reducing unnecessary burden.
    • Although no new clinical trials have directly compared different monitoring schedules, experience during the COVID‑19 pandemic offered valuable real‑world insight. During that period, monitoring was reduced out of necessity to protect vulnerable people, limit infection risk in healthcare settings, and preserve capacity for acute and high‑dependency care.
    • Despite these constraints, outcomes did not worsen significantly, suggesting that some patients may safely be monitored less often.
    • The guideline development group concluded that monitoring should be tailored to the individual. A standard schedule provides a useful starting point, but certain characteristics—such as comorbidities, interacting medicines, or reduced kidney function—can increase the likelihood of toxicity. In these situations, a more frequent monitoring schedule is appropriate to ensure safe and effective treatment.

Biologic DMARD monitoring

• • The information on monitoring of biologic DMARDs is based on expert opinion in the British Society for Rheumatology Biologic DMARD safety guidelines in inflammatory arthritis [Holroyd, 2018], and Guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs [BSR, 2026], the Yorkshire Rheumatology Regional Guidelines for the monitoring of adult patients on conventional disease modifying drugs, biologic drugs and targeted synthetic drugs [Tran, 2019], and the British National Formulary (BNF) [BNF, 2026].
    • The BSR states that there is no evidence on the optimal monitoring requirements for people receiving biologics but, in view of the potential risks and need to ensure a satisfactory clinical response, review should be carried out at least every 6 months by a rheumatology specialist [Holroyd, 2018]. 
    • The BSR also recommends that people prescribed a biologic (other than tocilizumab) should have monitoring blood tests (FBC, creatinine/calculated GFR, ALT and/or AST and albumin) every three to six months [Holroyd, 2018].

Targeted synthetic DMARD monitoring

• The information on monitoring of targeted synthetic DMARDs is based on information from the BNF [BNF, 2026] and extrapolated from within individual drug SPCs which describe common adverse effects [EMC, 2025a; EMC, 2025b; EMC, 2025c; EMC, 2025d; EMC, 2025e; EMC, 2026].
  • The SPC for apremilast highlights that use has been associated with psychiatric disorders, including suicidal ideation [EMC, 2026]. The BNF highlights that prescribers should monitor for psychiatric symptoms (including depression, suicidal ideation and behaviour) and discontinue treatment if new or worsening psychiatric symptoms are identified [BNF, 2026].
  • The BNF advises that people taking a JAK-I should be offered periodic monitoring of liver function; lipid profile 8 weeks after treatment initiation and then periodically, lymphocytes at baseline and every 3 months thereafter; neutrophils and haemoglobin at baseline, after 4 to 8 weeks of treatment and every 3 months thereafter [BNF, 2026]. As treatment is generally established in secondary care, CKS has advised ongoing monitoring of full blood counts 3-monthly, and (pragmatically) liver function at the same interval.
  • CKS did not locate any specific guidance regarding monitoring of renal function. The monitoring recommendation is therefore pragmatic, based on what CKS consider good clinical practice as well as extrapolated from guidance about monitoring other DMARDs.
  • The BNF highlights an MHRA recommendation for periodic skin examination in all people taking a JAK-I, particularly those at increased risk of skin cancer [BNF, 2026].

Basis for recommendation

These recommendations are based on the British Society for Rheumatology (BSR) Guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs [BSR, 2026], the Herefordshire and Worcestershire Integrated Care System Shared Care Guidelines for the use of Disease-Modifying Anti-Rheumatic Drugs (DMARDs) [Herefordshire and Worcestershire Integrated Care System, 2026], the American College of Rheumatology Guideline for the treatment of rheumatoid arthritis [Fraenkel, 2021], the Summary of Product Characteristics (SPC) for tocilizumab [EMC, 2024], and the British National Formulary (BNF) [BNF, 2026].