DMARD Monitoring

Conventional synthetic DMARD

Methotrexate

Used for

RA, psoriatic arthritis, JIA, PMR and GCA (steroid-sparing), lupus arthritis and skin disease, myositis, uveitis

Before starting

• CBC, metabolic panel with creatinine, liver tests and albumin
• Hepatitis B (HBsAg, anti-HBc, anti-HBs) and hepatitis C
• Chest X-ray if none recent; PFTs if there is lung disease
• Pregnancy test when relevant; alcohol history
• BSR 2025: FIB-4 (and elastography if indicated) if there are liver risk factors; varicella immunity if no history of chickenpox, shingles or vaccination

Monitoring

• CBC, creatinine, ALT/AST (and albumin): every 2–4 weeks for 3 months or after a dose increase, then every 8–12 weeks, then about every 12 weeks when stable

Cautions

• Once weekly, never daily. Dosing errors cause serious toxicity.
• Folic acid alongside (often 1 mg daily or 5 mg weekly, per local practice)
• Avoid trimethoprim and trimethoprim-sulfamethoxazole (marrow suppression)
• Reduce the dose in kidney impairment; generally avoid if eGFR is below 30
• Limit alcohol
• New cough or breathlessness: consider pneumonitis

Pregnancy

Contraindicated. Stop 1–3 months before trying to conceive.

Breastfeeding

Generally avoided. EULAR 2024: may be considered at 25 mg/week or less if no compatible alternative exists.

Men planning conception

May be continued (25 mg/week or less, EULAR 2024).

Vaccines

Inactivated vaccines are fine. Consider holding for 2 weeks after influenza vaccination if disease allows (ACR 2022).

Antimalarial

Hydroxychloroquine

Used for

Lupus (recommended for nearly all patients), Sjögren's arthralgia, RA (often in combination), APS in pregnancy

Before starting

• Baseline retinal exam with OCT and fundus autofluorescence soon after starting (AAO 2026)
• Kidney function (dose adjustment in CKD)

Monitoring

• Annual retinal screening (OCT plus wide-field autofluorescence) after 5 years of use, or from the start with risk factors: a dose above 5 mg/kg/day, kidney disease, tamoxifen, or starting at an older age
• Routine blood monitoring is generally not needed

Cautions

• Dose 5 mg/kg/day of actual body weight or less. In severe obesity, start lower and keep to 400 mg/day or less (AAO 2026).
• QT prolongation is possible, especially with other QT-prolonging drugs
• Rare hypoglycemia; skin hyperpigmentation with long use

Pregnancy

Compatible. In lupus, continue through pregnancy; stopping raises flare risk.

Breastfeeding

Compatible.

Men planning conception

Compatible.

Vaccines

No restrictions.

Conventional synthetic DMARD

Sulfasalazine

Used for

RA, peripheral spondyloarthritis, psoriatic arthritis, enteropathic arthritis

Before starting

• CBC, metabolic panel with liver tests

Monitoring

• CBC and liver tests on the methotrexate schedule. Some shared-care protocols reduce testing after the first year of stable results.

Cautions

• Avoid with sulfonamide allergy
• Orange urine and tears (can stain contact lenses)
• Rash, leukopenia and hepatitis are most common in the first 3 months

Pregnancy

Compatible (with folic acid supplementation).

Breastfeeding

Compatible in healthy term infants.

Men planning conception

Can be continued; it can reversibly reduce sperm quality, so consider stopping if conception is delayed.

Vaccines

No restrictions.

Conventional synthetic DMARD

Leflunomide

Used for

RA, psoriatic arthritis

Before starting

• CBC, metabolic panel with liver tests
• Blood pressure and weight
• Hepatitis B and C
• Pregnancy test when relevant

Monitoring

• CBC, ALT and creatinine on the methotrexate schedule
• Blood pressure and weight at checks

Cautions

• Very long half-life: accelerated elimination (cholestyramine) is needed for pregnancy plans or serious toxicity
• Hepatotoxicity (caution with alcohol and liver disease); hypertension; diarrhea; weight loss; peripheral neuropathy

Pregnancy

Avoid. EULAR 2024: stop about 3.5 months (five half-lives) before conception, or use accelerated elimination with cholestyramine. The US label advises accelerated elimination and confirming teriflunomide levels below 0.02 mg/L, since levels can otherwise persist for up to 2 years.

Breastfeeding

Avoid.

Men planning conception

May be continued (EULAR 2024).

Vaccines

Inactivated vaccines are fine.

Immunosuppressant

Azathioprine

Used for

Lupus maintenance, vasculitis maintenance, myositis, autoimmune hepatitis and IBD overlap, steroid-sparing

Before starting

• TPMT activity or genotype (and NUDT15 where available)
• CBC, metabolic panel with liver tests
• Hepatitis B and C

Monitoring

• CBC and liver tests every 2 weeks at first, then on the standard schedule

Cautions

• Febuxostat is contraindicated with azathioprine. Allopurinol needs a large azathioprine dose reduction (often to a quarter to a third) under specialist advice, or an alternative
• Skin cancer risk: sun protection and skin checks
• Pancreatitis, hepatotoxicity

Pregnancy

Compatible (generally up to 2 mg/kg/day).

Breastfeeding

Compatible.

Men planning conception

Compatible.

Vaccines

Inactivated vaccines are fine. Live vaccines generally avoided.

Immunosuppressant

Mycophenolate (MMF, mycophenolic acid)

Used for

Lupus nephritis, systemic sclerosis and ILD, vasculitis maintenance, myositis

Before starting

• CBC, metabolic panel with liver tests
• Hepatitis B and C
• Pregnancy test; reliable contraception

Monitoring

• CBC and liver tests every 2 weeks at first, then on the standard schedule

Cautions

• Teratogenic: two forms of contraception, or one highly effective method
• GI upset, infections, skin cancer

Pregnancy

Contraindicated. Stop at least 6 weeks before conception and switch to a compatible drug.

Breastfeeding

Avoid.

Men planning conception

May be continued (EULAR 2024). The US label advises contraception for male patients or their partners during treatment and for at least 90 days after, and no sperm donation in that time.

Vaccines

Inactivated vaccines are fine; responses may be reduced.

Calcineurin inhibitors

Tacrolimus, cyclosporine, voclosporin

Used for

Lupus nephritis (voclosporin, tacrolimus), myositis, uveitis

Before starting

• Blood pressure, creatinine/eGFR, potassium, magnesium, glucose, lipids
• Hepatitis B and C

Monitoring

• BP, creatinine and electrolytes often (every 2 weeks at first); drug levels for tacrolimus and cyclosporine

Cautions

• Many drug interactions through CYP3A4 (azoles, macrolides, grapefruit)
• Nephrotoxicity, hypertension, tremor, hyperglycemia

Pregnancy

Tacrolimus and cyclosporine are compatible; voclosporin is avoided (insufficient data).

Breastfeeding

Tacrolimus and cyclosporine compatible.

Men planning conception

Tacrolimus and cyclosporine compatible; limited data for voclosporin.

Vaccines

Inactivated vaccines are fine.

Glucocorticoid

Glucocorticoids (prednisone, prednisolone)

Used for

Many conditions; bridging while DMARDs take effect

Before starting

• Blood pressure, glucose or HbA1c, weight
• Fracture risk (FRAX; DXA if 2.5 mg or more is expected for 3 months or more)

Monitoring

• BP, glucose and weight at visits; bone health per GIOP guidance; eyes for cataract and glaucoma

Cautions

• Taper after more than about 3 weeks; risk of adrenal insufficiency
• Consider Pneumocystis prophylaxis with high doses plus another immunosuppressant
• Infection risk rises with dose

Pregnancy

Prednisone and prednisolone can be used; aim for 5 mg/day or less where possible.

Breastfeeding

Compatible.

Men planning conception

Compatible.

Vaccines

Live vaccines are generally avoided at 20 mg/day or more for 2 weeks or longer.

Biologic

TNF inhibitors

Adalimumab, etanercept, infliximab, certolizumab, golimumab (and biosimilars)

Used for

RA, PsA, axSpA, JIA, uveitis, IBD-associated arthritis

Before starting

• TB screening (IGRA preferred)
• Hepatitis B (HBsAg, anti-HBc, anti-HBs) and hepatitis C; HIV if at risk
• CBC and liver tests
• Vaccines updated (zoster, pneumococcal) ideally before starting

Monitoring

• CBC and liver tests periodically (for example every 3–6 months; yearly in JIA per ACR 2026)
• Repeat TB screening if exposure risk continues
• Skin checks

Cautions

• Hold for serious infection; can reactivate TB and hepatitis B
• Avoid in moderate to severe heart failure and demyelinating disease
• Drug-induced lupus and paradoxical psoriasis can occur

Pregnancy

Can be continued throughout pregnancy (EULAR 2024). Certolizumab has minimal transfer across the placenta.

Breastfeeding

Compatible.

Men planning conception

Compatible.

Vaccines

No live vaccines on treatment. Infants exposed in late pregnancy: discuss live vaccines (rotavirus, BCG) in the first 6 months.

Biologic

IL-6 receptor inhibitors

Tocilizumab, sarilumab

Used for

RA, GCA, PMR (sarilumab), JIA, SSc-ILD (tocilizumab)

Before starting

• TB and hepatitis B/C screening
• CBC (neutrophils, platelets), liver tests, lipids

Monitoring

• CBC and ALT/AST at 4–8 weeks, then about every 3 months
• Lipids 4–8 weeks after starting, then periodically

Cautions

• Suppresses CRP and fever, so infections can present with few signs
• GI perforation risk, especially with diverticulitis
• Neutropenia, raised liver enzymes

Pregnancy

May be used if needed (EULAR 2024); often stopped at conception if alternatives exist.

Breastfeeding

Considered compatible (minimal transfer).

Men planning conception

Compatible.

Vaccines

No live vaccines on treatment.

Targeted synthetic DMARD

JAK inhibitors

Tofacitinib, baricitinib, upadacitinib

Used for

RA, PsA, axSpA, GCA (upadacitinib), JIA

Before starting

• TB and hepatitis B/C screening
• CBC with lymphocytes and neutrophils, hemoglobin, liver tests, lipids, creatinine
• Recombinant zoster vaccine before starting where possible
• Cardiovascular, VTE and cancer risk review

Monitoring

• CBC and liver tests at 4–8 weeks, then about every 3 months
• Lipids at 4–8 weeks for tofacitinib, or about 12 weeks for baricitinib and upadacitinib

Cautions

• FDA boxed warning: serious infections, death, cancer, major cardiovascular events and thrombosis. Extra caution at age 50 or older with CV risk factors, in current or past smokers, and with a VTE history.
• Herpes zoster risk is higher than with biologics

Pregnancy

Avoid. Stop before conception (timing per agent).

Breastfeeding

Avoid.

Men planning conception

Limited data; consider switching.

Vaccines

No live vaccines on treatment.

Biologic (B-cell depleting)

Rituximab

Used for

RA, ANCA vasculitis, lupus, myositis, IgG4-related disease

Before starting

• Hepatitis B (HBsAg and anti-HBc; high reactivation risk) and hepatitis C
• Immunoglobulins (IgG, IgA, IgM), CBC
• TB screening per local protocol
• Vaccines given at least 2 weeks before where possible

Monitoring

• CBC and immunoglobulins before each cycle (often about every 6 months)
• Watch for late-onset neutropenia

Cautions

• Hypogammaglobulinemia and recurrent infections
• Hepatitis B reactivation; antiviral prophylaxis is often needed if anti-HBc is positive
• Vaccine responses are blunted for 6 months or more

Pregnancy

May be used if needed for severe disease (EULAR 2024). B-cell depletion in the newborn is possible after exposure late in pregnancy.

Breastfeeding

Considered compatible.

Men planning conception

Compatible.

Vaccines

Time inactivated vaccines before a cycle. No live vaccines.

Biologic (T-cell costimulation blocker)

Abatacept

Used for

RA, PsA, JIA

Before starting

• TB and hepatitis B/C screening

Monitoring

• No routine laboratory monitoring is needed in JIA (ACR 2026); periodic CBC in adults is common practice

Cautions

• Possible worsening of COPD
• Infection risk

Pregnancy

May be used if needed (EULAR 2024).

Breastfeeding

Considered compatible.

Men planning conception

Compatible.

Vaccines

No live vaccines on treatment.

Biologic

IL-17 and IL-23 pathway inhibitors

Secukinumab, ixekizumab, bimekizumab (IL-17); ustekinumab, guselkumab, risankizumab (IL-12/23 and IL-23)

Used for

PsA, psoriasis; IL-17 inhibitors also for axSpA. The 2026 ACR guideline advises against IL-23 inhibitors for axSpA.

Before starting

• TB and hepatitis B/C screening

Monitoring

• Clinical review; periodic CBC per label

Cautions

• IL-17 inhibitors: mucocutaneous candidiasis; may worsen IBD (avoid in active IBD)

Pregnancy

Secukinumab, ixekizumab and ustekinumab may be used if needed; guselkumab and risankizumab only if there is no alternative (EULAR 2024).

Breastfeeding

Generally considered compatible, with limited data for several agents.

Men planning conception

Compatible for most; limited data for guselkumab and risankizumab.

Vaccines

No live vaccines on treatment.

Biologic (lupus)

Belimumab and anifrolumab

Used for

SLE; belimumab also for lupus nephritis

Before starting

• Hepatitis B and C; TB screening per local protocol
• CBC, immunoglobulins
• Mood history (belimumab)

Monitoring

• CBC and clinical review at lupus visits

Cautions

• Belimumab: depression and suicidality warnings; infusion reactions
• Anifrolumab: herpes zoster and respiratory infections

Pregnancy

Belimumab may be used if needed; anifrolumab only if no alternative (EULAR 2024).

Breastfeeding

Limited data; belimumab considered compatible.

Men planning conception

Belimumab compatible; limited data for anifrolumab.

Vaccines

Consider recombinant zoster vaccine before anifrolumab. No live vaccines.

Biologic

IL-1 inhibitors

Anakinra, canakinumab, rilonacept

Used for

Still's disease and systemic JIA, autoinflammatory fevers (CAPS, colchicine-resistant FMF, TRAPS, MKD), recurrent pericarditis, refractory gout flares (canakinumab)

Before starting

• TB and hepatitis B/C screening
• CBC (neutropenia with anakinra)

Monitoring

• CBC periodically (anakinra: more often in the first months)

Cautions

• Injection-site reactions (anakinra)
• Infections

Pregnancy

Anakinra and canakinumab may be used if needed (EULAR 2024).

Breastfeeding

Considered compatible.

Men planning conception

Compatible.

Vaccines

No live vaccines on treatment.

Oral targeted therapies (PDE4 and TYK2 inhibitors)

Apremilast and deucravacitinib

Used for

Psoriatic arthritis and psoriasis (deucravacitinib was approved for PsA in 2026); apremilast also for Behçet's oral ulcers

Before starting

• Apremilast: no routine labs; kidney function for dosing
• Deucravacitinib: TB screening and baseline labs per label

Monitoring

• Apremilast: weight and mood
• Deucravacitinib: periodic labs per label

Cautions

• Apremilast: diarrhea and nausea early on, weight loss, depression
• Deucravacitinib: infections, acne

Pregnancy

Apremilast: avoid (insufficient data). Deucravacitinib: limited data; generally avoided.

Breastfeeding

Avoid (insufficient data).

Men planning conception

Limited data.

Vaccines

Inactivated vaccines are fine.

Anti-inflammatory

Colchicine

Used for

Gout flares and prophylaxis, CPPD, FMF, pericarditis, Behçet's

Before starting

• Kidney and liver function; review interacting drugs

Monitoring

• CBC and CK if on long-term high doses or with CKD

Cautions

• Reduce the dose in CKD
• Serious interactions with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, some azoles, cyclosporine)
• Myopathy, especially with statins and CKD

Pregnancy

Compatible.

Breastfeeding

Compatible.

Men planning conception

Compatible.

Vaccines

No restrictions.

Urate-lowering therapy

Allopurinol and febuxostat

Used for

Gout

Before starting

• Serum urate, eGFR, liver tests
• Consider HLA-B*58:01 before allopurinol in patients of Southeast Asian descent and African American patients

Monitoring

• Urate after each dose increase (often every 2–5 weeks) until below 6 mg/dL, then about every 6 months

Cautions

• Allopurinol hypersensitivity syndrome: start low (100 mg or less; lower in CKD) and stop for rash
• Interaction with azathioprine and mercaptopurine
• Febuxostat: FDA boxed warning for cardiovascular death; ACR 2020 suggests switching if there is cardiovascular disease or a new CV event

Pregnancy

Usually avoided; gout is uncommon in pregnancy.

Breastfeeding

Limited data.

Men planning conception

Limited data; generally continued.

Vaccines

No restrictions.