Ep 31. GUIDELINES - BSR guideline for the prescription and monitoring of csDMARDs 2025

BSR has published an updated life-course guideline for the prescription and monitoring of conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs).

Find out more via our blog. 

Join guideline working group Chair, Louise Mercer, and group members James Galloway, Katie Bechman, Akhila Kavirayani and Alan Davidson, in a roundtable discussion hosted by Prof Ernest Choy, Editor in Chief of Rheumatology to find out what is included in the publication and what has changed since the 2017 guideline was published. 

Find the video version of this episode on the BSR YouTube channel. 

Read the full guideline and download the handy infographic and audit tool here. 

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BSR is the UK's leading specialist medical society for rheumatology and MSK health professionals. To discover how we can support you in delivering the best care for your patients, visit our website.

Transcript

Ernest Choy   16:36
 Welcome to this episode of the BSR’s Rheumatology Roundtable, and today we're going to be speaking to the authors of the updated BSR guideline for conventional synthetic DMARDs. I'm Ernest Choy, Editor in Chief of Rheumatology, Oxford.
And I'm going to ask all our speakers to introduce themselves, starting with Louise.
Louise Mercer   17:07
 Hello, I'm Louise Mercer. I'm a consultant rheumatologist at Stepping Hill Hospital in Stockport, and I've had the pleasure of chairing this guideline working group.
Ernest Choy   17:17
 Katie.
Katie Bechman   17:18
 Hi, I'm Dr Katie Beckman. I'm a consultant at Kings College Hospital and a senior clinical lecture at Kings College London.
Ernest Choy   17:25
 Akhila.
Akhila Kavirayani 17:27
 I'm Akhila Kavirayani, Consultant Paediatric Rheumatologist at Oxford University Hospitals and I represent the paediatric subsection of the csDMARDs GWG.
Ernest Choy   17:39
 Alan.
Alan Davidson  17:41
 Hi everyone, I'm Alan Davidson. I'm a Clinical Nurse Specialist working in adult rheumatology in the community in Birmingham and I've been representing the nurses on the group guideline.
Ernest Choy   17:52
 Last but not least, James.
James Galloway   17:54
 Hi, I'm James Galloway. So I'm an adult Consultant Rheumatologist in Kings College Hospital and Professor of Rheumatology and was the Chair of the previous guideline and a member of the Guideline Working Group here.
Ernest Choy   18:07
 Welcome everyone. So in this episode, we're going to provide a summary of the key take-home messages from this updated guideline and how we can help clinicians to manage patients taking these medications. So I want to start off with Louise, can you start by giving us an overview of the guideline? Why was an update needed and what is new about this version?
Louise Mercer   18:31
 Thank you. Yes, we needed an update because the previous version actually went back to 2017 and that was a very important guideline at its time. It introduced for us, for the first time, hydroxychloroquine retinopathy monitoring and also harmonised blood monitoring. And we build on these areas in this current guideline.

 I think probably the most important thing to start with is the fact that this new 2025 guideline includes the whole life course, so children and adolescents, as well as adults, and, as part of the guideline working group, we've had paediatric rheumatologists, paediatric pharmacists and also specialist nurses.
 And so we could try and make guidelines where possible that were harmonised across the life course. The guideline also reflects several changes in clinical practice since 2017. We're all used to seeing new biologic drugs, of course, but new DMARDs don't come along very often. But we're very happy to include voclosporin as a new csDMARD in this current guideline. 

There's been significant advances in evidence around vaccines and people with rheumatic diseases, particularly in relation to optimising responses and people taking methotrexate. And this, of course, includes the COVID vaccines and studies, which wasn't even on the horizon back in 2017.

 Along with this, there's been changes in the general population health. I think overall, on average, we're becoming less healthy, in some ways, with more obesity and more fatty liver diseases such as MASLD (metabolic dysfunction-associated steatotic liver disease), previously known as NAFLD (non-alcoholic fatty liver disease), which now affects up to 30% of our general population. And this can be quite challenging for our patients and care providers in relation to safe prescribing and monitoring of DMARDs. For example, when we pick up raised liver enzymes, and for this updated guideline, we wanted to look at a more risk-adapted approach to prescribing and monitoring our drugs.

 Ernest Choy   20:20
 Great. James, since there's a need to update this because of changes in patient risk factors, new medications, new clinical circumstances and new practice, how was the guideline developed?
James Galloway   20:38
 Yeah, so the guideline, in sort of line with guideline development methodologies and the other BSR guidelines, it's an enormous amount of work going back over several years. These guidelines take huge amounts of effort. Firstly, to map the scope of the guideline and we have a scope document that was published, to bring the stakeholders together. To then craft the questions and to do the literature searching in the evidence review. And I think it's really important to remember that the guidelines are not just about the evidence, but it's also about expert consensus around that evidence. The DMARDs guideline is an area where there are pockets where there is an absence of evidence to build upon. So this is about a multi-stakeholder project, providing evidence-based recommendations and expert opinion around how we can best safely prescribe DMARDs.
Ernest Choy   21:29
 Katie, can you give us an overview of some of the key recommendations people can find in the guideline, especially how they may differ from the previous versions?
Katie Bechman   21:40
 Yeah, so these guidelines certainly have a greater emphasis on screening for infection before starting csDMARD therapy and several new recommendations have been added. And these include screening for latent TB (tuberculosis) in individuals who are at risk. Screening all adults for hepatitis B, hepatitis C and HIV, and checking varicella immunity in all children and in adults who have not had prior infection or previous vaccination. And this greater emphasis on screening really reflects the rising prevalence of some of these viral infections in the UK, the national shift towards opt-out screening and the availability of infective antiviral therapies, and the aim is to prevent severe complications that may occur if undiagnosed infections are present when immunosuppression is started. And, just to reiterate that, screening for infection should not delay the initiation of csDMARDs. 

The second new recommendation that we've introduced is also about screening, and this is about screening for liver disease in individuals, particularly adults, who are at risk before starting methotrexate. So the recommendation states that, in those with risk factors, a non-invasive fibrosis score, which is the FIB-4, should be performed, followed by a liver elastography, for example a FibroScan®. For those who are unfamiliar with FIB-4, this uses variables that are collected in clinic, age, AST, ALT, and platelet count, to estimate a fibrosis risk, which helps guide whether further liver assessment or referral is warranted.

 And, given the risk for methotrexate related liver disease in high risk individuals, the guideline working group thought that it was essential to be screening and monitoring for this. And this approach, in regards to the non-invasive fibrosis score, is in keeping with what NICE recommends for screening for MASLD. But, again, as we talked about the screening for infection, this should not delay initiation of methotrexate. The last recommendation that I wanted to discuss is a notable change to 2017, which is the relaxation of blood screening or blood monitoring for csDMARDs. And this reflects evolving clinical practice and some of the insights that we gained from the COVID-19 pandemic. 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 bloods should be checked at week two after starting the csDMARD and then monthly for the first three to six months and in individuals with risk factors for toxicity and more frequent monitoring is advised. In the maintenance phase, and individuals without risk factors for toxicity, maintenance  bloods should be carried out at three-monthly intervals. However, this can be extended following an individualised benefit-risk assessment. And, really, we feel this recommendation balances patient safety with practical, sustainable care. I'm going to handover to Akhila now who's just going to talk through some of the differences between the adults and children within this guideline.

 Akhila Kavirayani 24:50
 Thanks, Katie. First of all, I highly commend the BSR initiative to include children and young people within the same guideline framework, and thank you so much for this opportunity and it's a privilege to speak on behalf of the paediatric group. I think it's important to remember that children are not small adults. It's often quoted, but it's a very true statement. Some of the key differences for children and young people in this guideline are some of which Katie has already alluded to. But, just to make it clear, there is clear guidance on blood monitoring, including specific tests, for example, testing for varicella and measles is in all children at baseline, which is in slight variance to the adult recommendations. Again, we have addressed frequency of monitoring, accounting for practical problems with phlebotomy in young children. For example, the week two test is optional in children in this guideline. We've given additional information on interpretation of abnormal results which is in a clear table format, alongside the adults guidelines. And we encourage shared care with primary care providers, all whilst ensuring strong support, in fact, from the tertiary paediatric rheumatology centres. Also, due to differences in comorbidities between adults and children, certain scoring systems or investigations are less relevant in children, such as FIB-4 or the FibroScan® and baseline testing for hepatitis and HIV is not routinely recommended when commencing csDMARDs in children, unless of course it's clinically indicated. We also have to remember some medicines are not routinely yet used in paediatrics, for example, voclosporin, minocycline and apremilast is not licenced or approved for using children apart from in ongoing clinical trials.
Thank you.
Ernest Choy   26:47
 And, Akhila, why do you think it is important for this guideline to be expanded to include the whole life course?
Akhila Kavirayani 26:55
 Thank you, Ernest. So covering the whole life course enables seamless transition and thereby effective transfer of care and it is a more cohesive and joined-up process between children and the adult services which has a multitude of advantages in all facets of effective disease management, it not only empowers families and patients and children and young people, but also empowers clinicians across all tiers, including primary, secondary and tertiary, bearing in mind that a select few clinicians are in fact life-course rheumatologists. We, however, have to acknowledge and accept the fact that, obtaining high-quality evidence to guide recommendations in children can be quite challenging. In fact, to lessen ambiguity in this guideline, we have tried to carefully balance available evidence in children, including evidence that can be extrapolated from adult studies. We've derived information from existing international guidelines, including those from Europe or North America, and we've obtained expert consensus, including national consensus, where applicable.
Ernest Choy   28:06
 Fantastic. I want to turn to Alan. There are nurses involved in the guideline’s development, including yourself. How do you think the updated guidelines will be used and help rheumatology nurse specialists in their practise?
Alan Davidson  28:21
 Thank you, Ernest. So I think nurses have and will always continue to play a key role in supporting patients with their medications, whether it's initiating those or monitoring those. So this this guidance really helps give us, you know, clear evidence-based guidance and will enhance patient safety and provide consistency which I think is really important up and down the country. But also I think, regardless where you're sitting in primary care and secondary care, will really help with that. This will go across the board. And also having the life-long guidance as well. 

But I think recently, certainly in the last five years, COVID and beyond, but even prior to that, a lot of nurses, experienced, nurses are leaving. So we have a a whole new raft of nurses coming in, which is really exciting of course. But I think this will really help us now, kind of, we can use some of the things that perhaps were mentioned earlier. The infographic – it’s quite easy to see that; it's very clear, very concise, which I think would be great.

 But also there's an audit form which also comprises a checklist and I think for nurses that'd be really helpful that can be used as a checklist. So those are perhaps less experienced, but actually for all of us, this is new, this is new to us and there are quite significant changes. So I think it's really good to have the guidance with us now and moving forward for the next generation of nurses coming in to us.

 Ernest Choy   29:53
 Great. James, we heard why the update is necessary and there are important changes to screening and monitoring. How can listeners find help to implement the guideline?
James Galloway   30:07
 So I hope the guideline is - it is accessible to users. The first thing is to say that, obviously, each of the individual statements - you can look at the individual statements and read those through as sort of a cohesive group and that gives you the comprehensive view of each of the different steps. We've got some other tools though that are really useful. There's, within the guideline document, I'd really encourage people to explore it, there's some great tables, for example, the renal table has been updated and provides a comprehensive overview of prescribing in renal disease. There's an infographic has been mentioned that the infographic is a really good summary of key changes and some headline findings.
 
 

And there's also an audit tool in the guideline which allows people to sort of take out the key bits and then say - how are we performing against them at a local level. So I hope there's lots of things within the guideline and there may well be people or listeners who create their own and maybe want to share those in due course, because I think there's lots of things that can be done with the framework from the guideline.

 Ernest Choy   31:06
 OK. And finally, coming back to you, Louise. What do you want to encourage listeners to pay particular attention to in the new guideline?
Louise Mercer   31:15
 Thank you. Yes. And I think the overarching statements and the infographic as, Alan said, give a really good snapshot and introduction to what the new guideline’s all about. And then, as James said, there's an absolute wealth of information under the surface.
 
 

And I think that different readers will be able to dip in and pick out different bits that are important to them. For example, you know, a patient rings about low neutrophil count. Well, there's now clear guidance on what we suggest you could do in that situation. Somebody wants to have a vaccine. What if it's a live vaccine? What if it isn't? So there's lots of areas in the guideline where there's some more detailed information that can inform those patient and clinician discussions.

 Ernest Choy   31:56
 So, thank you very much everyone for updating us on the new updated BSR guidelines on csDMARDs. I hope all of you have enjoyed listening to the members of the working group.

 All the BSR guidelines and then resources are available from the BSR guideline page on their website, and I hope that you will join us in the future episodes of Rheumatology Roundtable. Thank you.