I am most concerned about 2 things when I am monitoring my patients. First, I am checking for efficacy, to ensure that the medication is significantly improving symptoms (eg, morning stiffness, joint swelling, joint pain) and inducing remission. Simultaneously, I am also checking to ensure that my patients are tolerating the medication well, which involves several different factors. For example, is the patient able to physically take the medication regularly? When the regimen includes methotrexate (MTX), some individuals are nonadherent because they develop anticipatory nausea from the MTX or nausea after administration. With biologics, injection site reactions are common and may prevent patients from adhering to their treatment.

Routine laboratory monitoring is also important for all patients receiving treatment for RA. For those with a treatment regimen that includes MTX, I typically perform blood work at least once every 3 months, and I am looking for evidence of cytopenias, drug-induced hepatotoxicity, and renal dysfunction. I also perform an assessment of systemic inflammation as yet another data point reflecting disease activity. Recommendations for laboratory monitoring for those receiving anti–tumor necrosis factor (anti-TNF) agents are less standardized, but I typically order the same blood work as I do with my patients on MTX, and I perform it once every 3 to 6 months.

At the same time, assessment for infectious diseases such as tuberculosis (TB) is particularly important in a newly diagnosed patient prior to the initiation of biologic therapy. I typically screen for TB using the interferon gamma release assay in all patients prior to initiating biologic therapy. I do not routinely recheck TB status in a patient on a biologic, except if there has been a potential exposure to TB, travel to an endemic area, or prior to switching to another agent. I also check hepatitis B and C serologies when patients are first diagnosed with RA, since positive results may impact their future care. With respect to the noninfectious complications of biologics, there is a reported contraindication of anti-TNF agents in patients with congestive heart failure, although the data regarding this risk in patients with RA are quite limited. I also ask my patients to be up to date with their age-appropriate cancer screening. The data on the effect of RA or its treatment on the development of skin cancers are still unclear, although I often recommend skin checks, especially for those with a family history of skin cancers.