New UK guidelines change frequency of blood testing, reflecting evolving evidence.
The British Society for Rheumatology has rewritten the rules on csDMARD monitoring, issuing a 2025 guideline that replaces routine, one-size-fits-all blood testing with a risk-adaptive approach grounded in new evidence.
For many long-term csDMARD users, especially those with stable disease and no clear toxicity risk factors, the constant cycle of blood monitoring may no longer be necessary.
Instead, the guideline advises clinicians to tailor testing frequency to each patient’s individual risk profile, reflecting new data showing that blanket schedules place unnecessary burden on both patients and services without improving safety.
This targeted approach is intended to reduce avoidable monitoring, free up clinical capacity and support more personalised care, and marks one of the most practice-changing updates since the guideline’s last publication in 2017.
The new guideline brings together updated recommendations for adults, introduces detailed guidance for children and young people for the first time, and reflects several important changes in clinical practice.
The guideline has been published in Rheumatology, and was commissioned by the BSR Standards, Guidelines and Audit Working Group (now called the BSR Guidelines Steering Group).
Dr Louise Mercer, consultant rheumatologist at Stepping Hill Hospital and chair of the Guideline Working Group, said the update reflected developments that have reshaped routine care.
“The guideline reflects several changes in clinical practice since 2017, such as the inclusion of the csDMARD voclosporin, new evidence around optimising vaccine response in people taking methotrexate and the introduction of a risk adaptive approach to blood monitoring,” she said.
The guideline also makes recommendations on the actions for abnormal blood monitoring results.
“Blood monitoring during csDMARD therapy aims to identify early signs of potential toxicity, but it is important to recognise that most laboratory abnormalities encountered do not require alteration of treatment,” the authors wrote.
“Many minor changes are transient, resolve spontaneously and are often unrelated to the csDMARD itself, arising instead from intercurrent illness, disease activity or other non-drug-related factors.
“A measured response to abnormal results is essential. Trends over time should be reviewed alongside absolute values, and isolated abnormalities should be interpreted cautiously.
“Decisions regarding treatment interruption, dose adjustment or additional investigations should be individualised, with discussion with the treating rheumatology team where needed.”
Speaking at a roundtable discussion on the new guideline, working group member and rheumatology registrar Dr Katie Bechman described the relaxation of blood screening or blood monitoring for CsDMARDs as a “notable change”.
“This reflects involving clinical practice and some of the insights that we gained from the covid pandemic,” she said.
“And we now know from real world experience that in suggested in selected patients, less frequent monitoring may be safe, and so the guideline working group recommends a risk adaptive approach.
“So for the induction phase, when a csDMARD is started, in individuals without additional risk factors, for toxicity monitoring, blood should be checked at week two after starting the csDMARD and then monthly for the first three to six months.
“In individuals with risk factors for toxicity, more frequent monitoring is advised in the maintenance phase.
“In individuals without risk factors for toxicity, maintenance blood should be carried out at three monthly intervals. However, this interval can be extended following an individualised benefit risk assessment.
“Really we feel this recommendation balances patient safety with practical, sustainable care.”
Among the updated recommendations, the guideline also sets out that adults should withhold methotrexate for up to two weeks after influenza or covid vaccination where disease activity allows, while in children the decision should be individualised.
Screening for varicella immunity in all children and in adults with no prior history of chickenpox, shingles or VZV vaccination is suggested for patients who are commencing csDMARDs. In the paediatric age group, screening for immunity to measles is also recommended before starting csDMARD therapy.
The recommendations incorporate a more refined approach to liver-related risk at baseline, recommending that adults starting methotrexate who have risk factors for liver disease should undergo FIB-4 scoring, with elastography ordered if indicated. However, it emphasised that treatment should not be delayed while awaiting results.
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The guidance also advises that csDMARDs be paused during episodes of severe infection requiring hospital admission or intravenous therapy.
Throughout the document, clinicians were encouraged to reassess risk factors for csDMARD toxicity annually and adjust monitoring frequency accordingly, supporting the shift away from rigid schedules.
The 2025 guideline also places new emphasis on coordinated, shared-care arrangements between rheumatology services and primary care.
It states that locally agreed shared-care plans should be in place whenever prescribing was transferred, and that these plans should include paediatric teams where relevant, reinforcing the guideline’s new whole-life-course remit.
That life-course approach is a defining feature of the update, allowing patients to transition between child and adult services under a single, consistent framework.
Dr Akhila Kavirayani, a consultant paediatric rheumatologist at Oxford University Hospitals, said that extending the guideline to include children and young people brought clear benefits to continuity and safety.
“Covering the whole life course enables seamless transition and thereby effective transfer of care to create a more cohesive and joined-up process between children and the adult services,” she said.
“This has a multitude of advantages in all facets of effective disease management; it not only empowers families and children and young people but also empowers clinicians across all tiers.”
The guideline further recognises the central role of nurses in csDMARD education, monitoring and safety-netting.
Alan Davidson, an adult rheumatology clinical nurse specialist working in Birmingham, welcomed the clarity the updated document provided.
“Nurses have and will always continue to play a key role in supporting patients with their medications, whether it’s initiating or monitoring those,” he said.
“This guideline really helps give us clear evidence-based guidance and will enhance patient safety and provide consistency across the country.”
In addition to refreshed recommendations on dosing and monitoring of widely used csDMARDs, including methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, azathioprine, ciclosporin, tacrolimus, mycophenolate, mepacrine, minocycline, apremilast and the newly added voclosporin, the guideline is accompanied by a suite of implementation resources.
These include an exclusive introduction video from Dr Mercer, a roundtable discussion led by Professor Ernest Choy, a csDMARDs infographic and audit tool, and the full guideline and scope. All materials are openly accessible through a dedicated collection on British Society for Rheumatology e-learning. See here for more information.
The planned review date for this guideline will be 2028. However, in the interim, significant alterations to this guideline will be updated on the BSR website.
