The development of a risk threshold to aid risk stratified approach to monitoring for haematological, hepatic and/or renal adverse drug reactions during established conventional synthetic DMARD treatment for systemic autoimmune rheumatic diseases: a RAND/UCLA Appropriateness Method consensus study

Objective To explore how appropriate different intervals between monitoring blood tests are considered in relation to the risk of clinically significant adverse drug reactions in adults prescribed csDMARDs for ≥1 year for systemic autoimmune rheumatic diseases (SARD). Method A RAND/UCLA Appropriateness Method consensus study was undertaken. Members of the BSR csDMARD guideline working group who manage adults with SARD participated. Experts rated the extent to which intervals between blood tests were appropriate using Likert-type scales with responses from 1 (totally inappropriate) to 9 (totally appropriate) for 9 scenarios with 5-year predicted risk of discontinuing treatment due to abnormal monitoring blood tests from 5% to 25%. Median score and the number that voted 1–3 (inappropriate), 4–6 (unsure), and 7–9 (appropriate) were calculated for every interval in each scenario. Scenarios for which agreement could not be reached in the first round were recirculated, enclosing individual round one response and the panel median score. Consensus that an interval was appropriate for a scenario was reached where the median panel score was ≥7 and up to 6 experts rated <7. The results were discussed with PPI members and experts. Results Twenty-one of the 27 invitees participated. They comprised 11 consultants/GPs, five specialist nurses, three pharmacists, and two rheumatology specialty trainees. Consensus was reached for all scenarios. Six- and three-monthly blood tests were agreed as appropriate when the predicted risk was ≤10% and >10% over 5-years respectively. Conclusion A threshold to aid risk-stratified monitoring during established csDMARD treatment was agreed for adults with SARD.