Tests | Treatment | Drug Monitoring | Disease Monitoring
Drug Monitoring in IBD
Patients may be prescribed a range of different medicines for inflammatory bowel disease. As both patients and medical staff may access this page, links to the Lothian Shared Care Agreements and the COVID pandemic monitoring advice are provided, along with information for patients below.
Further Information, including printable patient information leaflets about the different medications, can be found on the CCUK website. www.crohnsandcolitis.org.uk
For medical staff
COVID 19 pandemic DMARD/immunomodulator monitoring
Modification to the frequency of blood monitoring for DMARDs/immunomodulators has been agreed by the Rheumatology and Gastroenterology specialists, with some reservations from Dermatology specialist services to protect patients and reduce pressure on NHS services during the COVID pandemic.
The changes detailed in the table below support a reduction in monitoring to every 6 months in stable patients (on current treatment for >12 months and at a stable dose for >6 weeks)
However, extending blood monitoring is not suitable if the patient has:
- poor renal function with CKD ≥ 3
- severe liver disturbance or abnormal liver results due to immunomodulators/DMARDs within previous 3 months
- severe abnormal WBC results due to immunomodulators/DMARDs within previous 3 months
Monitoring requirements are detailed in the Shared Care Agreement for each drug. If blood test results fall out with the specified parameters, plans for future monitoring should be discussed with the relevant specialist service.
| Drug Name | Current monitoring requirements | Modified monitoring requirements for those patients on current treatment for >12 months and at a stable dose for >6 weeks* |
| Azathioprine Shared Care Agreement | Every 2 weeks until patient on stable dose for 6 weeksThen monthly for 3 monthsThereafter every 3 monthsRevert to initial schedule if dose increased | Where azathioprine use has been successful and stable (see definition of stable above) consider extending the monitoring interval to up to every 6 monthsIf dose increased – blood tests required every 2 weeks until dose stable for 6 weeks, then 6 monthly |
| Methotrexate Shared Care Agreement | Every 2 weeks until patient on stable dose for 6 weeks. Then, monthly for 3 months.Thereafter every 3 months. | Where methotrexate use has been successful and stable use has been successful and stable (see definition of stable above) consider extending the monitoring interval to up to every 6 months. If dose increased or change from oral to subcutaneous blood tests required every 2 weeks until dose stable for 6 weeks, then 6 monthly. |
The SCA for mercaptopurine is available at formulary.nhs.scot/east/help-and-support/for-healthcare-professionals/shared-care-of-medicines/nhs-lothian-shared-care-agreements but no specific comment was made on the monitoring arrangements for this during COVID -19 restrictions.
For patients
A range of different medicines are used to treat inflammatory bowel disease. These medications may mean that we need to monitor you to check that the drug is working for you and to make sure you’re not having any side effects to the medicine. Below is a list of the medications we might use, how often we check your blood and who is responsible for checking your blood. Information about the different medications can be found on the CCUK website. www.crohnsandcolitis.org.uk
In addition to checking your blood tests, we will also ask for stool samples to check the level of inflammation in the bowel. The frequency of these will depend on your individual case.
Mesalazine (e.g. Mezavant XL, Pentasa, Asacol, Octasa, Salofalk)
You should have your renal function (kidney tests, or U+Es) checked 3 months after starting treatment, then annually while on treatment. You may still have other blood tests monitored for your IBD (for example your blood count, inflammation levels or iron levels) but this is the minimum monitoring requirement for this treatment. This monitoring can be performed either at your GP practice or through your IBD team.
Azathioprine, mercaptopurine, methotrexate
If you are started on these, your blood tests will be monitored by the hospital in the first 6 weeks of your treatment, and by your GP therafter. This has been agreed between the GP and hospital team and the relevant information is summarised in a Shared Care Agreement. This remains the case even if you are also on a biologic drug at the same time. The blood tests checked at these appointments are your blood count, liver and kidney tests (FBC, U+Es, LFTs). You may still have additional blood tests check through the clinic to look for low levels of iron, B12, folate and vitamin D.
Biologic treatments and Tofacitinib (without azathioprine, mercaptopurine, methotrexate)
If you are taking a biologic treatment (Infliximab, Adalimumab, Vedolizumab, Ustekinumab, Golimumab), or tofacitinib, your IBD team take responsibility for monitoring your blood tests. We will take “routine” blood tests approximately every 6 months. At each routine blood test for biologic treatments, we check your blood count (FBC), kidney tests (U+E), liver blood tests (LFTs), inflammation markers (CRP) and your albumin and calcium levels.
If you are also on azathioprine, mercaptopurine or methotrexate, you will need more frequent monitoring. This would usually be done by your GP as per the Shared Care Agreement mentioned above. There has been a change in the frequency of monitoring for stable patients during the COVID pandemic, summarised above.
Monitoring blood tests will be done while you are at the infusion suite for patients on IV therapies, or through a secondary care blood test appointment for patients on subcutaneous injections or tofacitinib.
We will also sometimes add in extra blood tests, usually about once a year. Currently we aim to check your iron, vitamin B12 and folate levels once a year, and are also checking Vitamin D levels annually.
Infliximab and Adalimumab drug levels
Both of these medications (anti TNF drugs) have an additional monitoring requirement. We will check your drug levels (and if low, anti-drug antibody levels) 12-14 weeks after starting treatment, and at least once a year thereafter. This helps us to make sure that you are receiving the right dose for you. This will be arranged by your IBD team.
Tofacitinib
This medicine can cause higher cholesterol levels. The information provided by the manufacturer recommends monitoring your blood count (FBC), lipid (cholesterol) levels and liver function tests (LFTs) 8 weeks after starting treatment. Thereafter you should have your blood count every 3 months and your lipid levels checked every year. You may have other blood tests arranged through your IBD team, for example to check for low iron levels or inflammation, although this is to monitor your IBD rather than the medication itself.
