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Recently released guidance from NHS England (NHSE) on optimising blood testing in primary and secondary care diverges from BSR’s NICE-accredited DMARD monitoring guideline (2017).


The revised guidance around DMARD monitoring is welcomed in the context of the blood tube supply shortage. However, we've contacted NHSE for comment on the implications of the advice in terms of patient safety.


The guidance was developed by an expert Clinical Reference Group (CRG) with wide representation in both primary care and secondary care, as well as being open to consultation to certain stakeholders. It's both specific to the acute shortage situation as well as best practice guidance applicable to day-to-day.


We've contacted NHSE to provide comments on 'Section 7.3 Rheumatology – monitoring of DMARDs’. We’ve been informed our comments have been passed on the lead author for consideration as the move is made towards more established guidance.


We suggested the following amendments to bring the guidance more in line with our existing DMARD monitoring guideline:


Additional criteria for the safety of patients with potential risk of DMARD toxicity

'For patients under shared care who have been on treatment for >12 months, don't have specific risk factors for DMARD toxicity, and where their last two blood monitoring tests have been normal and current dose has been stable for three months.'


To the table of drugs

  • Removal of penicillamine and mercaptopurine

  • Addition of the following rows with the same extended recommendation: leflunomide

  • Addition of the following additional rows with the recommendation 'No change in existing monitoring': (1) methotrexate/leflunomide combination therapy (2) mycophenolate (3) ciclosporin (4) tacrolimus

  • The latter group are a higher risk set of drugs/combinations


We'll update this piece if further information is provided by NHSE.