AB1831-HPR SYSTEMATIC REVIEW OF LABORATORY MONITORING GUIDELINES OF CONVENTIONAL SYNTHETIC DISEASE MODIFYING ANTI-RHEUMATIC DRUGS

Abstract

BackgroundConventional synthetic disease modifying anti-rheumatic agents (csDMARDS) have a significant role in the management of multiple rheumatological disorders. Several clinical practice guidelines (CPG) exist to guide practitioners in the appropriate frequency and type of laboratory monitoring during csDMARD use, however few appraisals of the quality of these guidelines have been performed.ObjectivesThe purpose of this study was to summarise the content and appraise the quality of CPGs for laboratory monitoring during csDMARD use.MethodsA systematic search of electronic databases, online guideline repositories and the websites of professional societies was conducted to identify CPGs for the frequency and type of laboratory monitoring in csDMARD use. A pair of reviewers screened CPGs using predetermined selection criteria and reported according to the PRISMA-P statement. Recommendations from included CPGs were extracted and compared across guidelines. The list of csDMARDS this study reviewed includes methotrexate, leflunomide, hydroxychloroquine, mycophenolate, sulfasalazine and azathioprine.Figure 1.ResultsThe review identified 19 sources, resulting in 33 guidelines for laboratory monitoring of conventional synthetic DMARDS (see table 1) Within the 33 guidelines seen there were 10 for methotrexate, 7 for sulfasalazine, 6 for leflunomide, 5 for hydroxychloroquine, 3 for azathioprine and 2 for mycophenolate. There was a notable variation in terms of detail, specifics and monitoring intervals.Table 1.Example of extracted laboratory monitoring guidelines for methotrexate (other csDMARDS not included for purposes of word count)DMARDLiver enzymesFull blood countRenal functionAdditional recommendationSourceMethotrexateBaseline, every 2-4 weeks for first 3 months, then every 8-12 weeks for following 3-6 months, every 12 weeks thereafter. More frequent monitoring in those at risk for complications.Baseline, every 2-4 weeks for first 3 months, every 8-12 weeks for 3-6 months after initiation, every 12 weeks thereafter.Baseline, every 2-4 weeks for first 3 months, every 8-12 weeks for following 3-6 months, every 12 weeks thereafter.American College Rheumatology (ACR)America2008MethotrexateEvery 2 weeks until stable dose for 6 weeks, then monthly for 3 months, every 12 weeks thereafterEvery 2 weeks until stable dose for 6 weeks, then monthly for 3 months, at least every 12 weeks thereafterEvery 2 weeks until stable dose for 6 weeks, then monthly for 3 months, at least every 12 weeks thereafterBritish Society Rheumatology (BSR)2017EnglandConclusionIn summary, this review identified several possible recommendations going forward. There is an argument to be made for a more uniform international guideline of laboratory monitoring to be synthesised, as there could be an element of uncertainty for those noting and comparing the variation between recommendations. A role for a more extensive review of the incidence of treatment complications and implications as a result of the laboratory monitoring would be of benefit. This poses an additional role for a cost-effective analysis, as was commented on within the discussion and literature reviews.Reference[1] Abstract not cited or published to date.Acknowledgements:NIL.Disclosure of InterestsNone Declared.