Royal College of General Practitioners - Online Learning Environment

Written by Dr Toni Hazell.

Disease modifying anti-rheumatic drugs (DMARDs) are widely used to treat inflammatory conditions, some of which are primarily rheumatological (e.g. rheumatoid arthritis), whilst others have their origin in another organ system (e.g. inflammatory bowel disease and psoriasis). DMARDs are started in secondary care; once the patient is stable, prescribing and monitoring is often done in primary care, under a resourced shared care agreement, with regular specialist review. 

In 2017, the British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) jointly published a guideline which significantly changed monitoring frequency, allowing many patients taking a single DMARD to move from monthly to 3-monthly monitoring¹. The most recent BSR update, published in 2025², makes further changes, aiming to individualise monitoring requirements. The drugs covered are apremilast, azathioprine, ciclosporin, hydroxychloroquine, leflunomide, mepacrine, methotrexate, minocycline, mycophenolate, sulfasalazine, tacrolimus and voclosporin.  The long-term prescribing and monitoring of biologic drugs remains the remit of secondary care, and they are excluded from this update. This blog will mainly cover the primary care relevant aspects of the update, rather than actions around the time that the drugs are started. It will focus on adults; the management of children on DMARDs is more complex and shared care is less common. 

The biggest change to the previous guidance is the concept that patients will be divided into those with or without risk factors for toxicity, and the monitoring schedule may vary according to this assessment. This assessment of risk factors should be done by the specialist before starting a new DMARD. Risk factors include CKD ≥3, increasing age, obesity, alcohol consumption, pre-existing liver disease, significant medical comorbidities, a history of DMARD related toxicity, cytopenia and raised liver enzymes in the last six months². The use of other medications which may affect DMARD metabolism or clearance might also be taken into account, A personalised approach to this assessment should be taken and the monitoring schedule in the first six months (during which time prescribing and monitoring is usually still done by secondary care) should be adjusted depending on whether the patient is deemed low, medium or high risk. 

Once a patient is stable on their medication, monitoring may be handed over to primary care, under the auspices of a resourced shared care agreement. For those without risk factors for toxicity, monitoring remains 3-monthly. This may be extended following an individualised risk-benefit assessment (done by the specialist), which may result in monitoring frequency changing to 6-monthly or less, but the interval between monitoring tests should never exceed 12 months. For those who have risk factors for toxicity, monitoring may need to be more frequent, again based on an individualised assessment done in secondary care. Certain combinations considered to be particularly risky (such as methotrexate plus leflunomide) need long-term monthly monitoring. The level of risk factors should be reviewed at least annually in secondary care, at which point the frequency of monitoring might be adjusted up or down. 

It is not the responsibility of the GP to decide on monitoring frequency, but if we are prescribing under shared care then we should be aware of any significant changes to the patient’s health status (such as hospital admissions, changes to other medication or symptoms that suggest toxicity) and it is always reasonable to communicate such information to the patient’s consultant if we think that they might not be aware of the information. Shared care can only take place if there is easy and effective communication between primary and secondary care^2,3; if such communication channels are not open then it is reasonable for the GP to decline to take on shared care, in which case long-term prescribing stays with secondary care³. The full guideline should be consulted for exact details of monitoring for specific drugs, being aware that some have requirements outside of blood tests, notably the need for eye checks for those taking hydroxychloroquine, the frequency of which again varies with risk factors. Shared care agreements should make it clear whether the responsibility for arranging these checks lies with the specialist, the GP or the patient. 

Other than monitoring, there are a few other issues with the GP should be aware of if they are prescribing under a shared care protocol. Patients on immunosuppressive therapy are eligible for a range of vaccinations including influenza (annually), pneumococcus (every 5 years), COVID-19 (eligibility and frequency currently reviewed annually) and shingles (one off set of two doses). The 2025 guidance specifies that, following influenza or COVID-19 vaccination, methotrexate should be ‘withheld for up to two weeks, assuming disease activity and/or risk of flare allows’. Pausing methotrexate in this way increases antibody response to the vaccines but must ‘be carefully balanced against the risk of [disease] flares’. GPs are unlikely to feel that making this risk/benefit assessment is within their skill set and it is hoped that specialists might include this information in clinic letters in the run-up to the flu vaccination season; if that doesn’t happen then practices might want to contact specialist teams to get this information. 

The question of whether to continue or pause a DMARD during intercurrent illness has always been a tricky one and this guideline offers some clarification, saying that in the event of a severe infection, they should be temporarily discontinued until the patient has recovered. A severe infection is defined as one requiring intravenous therapy or admission and the guidance specifies that DMARDs do not need to be paused for ‘minor infections’ – they give the example of an uncomplicated urinary tract infection. However, several DMARDs (particularly methotrexate) have significant antibiotic interactions such that finding a suitable antibiotic can be tricky and may need discussion with the patient’s specialist.

The 2025 update to the DMARD guideline offers the exciting potential that some patients on methotrexate may need to have monitoring only once or twice a year; a significant change to their quality of life from the days, less than a decade ago, when monitoring was monthly for all. It will however take time to embed and for secondary care to get used to making these risk assessments and advising on personalised monitoring. Safety is always paramount for these complex medications and when in doubt, getting advice from the patient’s specialist is always a sensible option. 

References: 

1. Ledingham J, Gullick N, Irving K et al. BSR and BHPR Standards, Guidelines and Audit Working Group. BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs. Rheumatology (Oxford). 2017 Jun 1; 56(6): 865-868.
2. Bechman K, Song K, Abhishek A et al. British Society for Rheumatology Guidelines Steering Group. The 2025 British Society for Rheumatology guideline for the prescription and monitoring of conventional synthetic disease-modifying anti-rheumatic drugs. Rheumatology (Oxford). 2026 Feb 4; 65 (2): keaf522. 
3. NHSE. Responsibility for prescribing between primary and secondary/tertiary care. Jan 2018. [Accessed August 2026].