Rheumatoid Arthritis Follow Up

Monitoring

To monitor for drug toxicity, complete blood count, serum creatinine, liver function tests, hepatitis B and C screening, ophthalmologic exam, latent TB screening (for bDMARDs, with chest X-ray) are requested. It is recommended to monitor patients for drug toxicity due to the potential risks of serious adverse effects prior to resuming or increasing therapy with DMARDs. 

Prior to tapering of therapy, patients should have a low disease activity or be in remission for at least 6 months. A dose reduction (decrease in dose or increase in the dosing interval) is recommended over gradual discontinuation of a DMARD along with a close evaluation of patients during any tapering of therapy. Patients in persistent remission can consider tapering bDMARD or tsDMARD therapy after tapering glucocorticoid therapy. Tapering of csDMARD treatment may also be considered. 

Flare risk is inversely proportional to disease activity and sustained response duration, thus, to decrease the risk of flares, gradual withdrawal of biological therapies should be done. As discontinuation of therapy is associated with a high risk of flares, careful reduction of dose or increase in the interval can be done with all bDMARDs and tsDMARDs with a little risk of flares. Most patients who flare can regain their prior good response upon prompt re-institution of the same bDMARD or tsDMARD therapy. Ceasing treatment with csDMARDs is associated with increased flare frequency, hence tapering should be done cautiously and should be evaluated rigorously. 

• Moderate-high disease activity: Monthly
• Sustained low disease activity or remission: Every 6 months 

Prognosis

Poor prognostic factors in patients with rheumatoid arthritis include a high count of swollen joints, evidence of early erosions, the presence of rheumatoid factor and/or anti-citrullinated protein antibody (particularly at high levels), high levels of acute phase reactants, moderate or high disease activity persisting despite treatment with csDMARDs based on composite measures including joint count, treatment failure with ≥2 csDMARDs, and other factors such as female gender, older age, smoking history, and presence of obesity or anemia.