Drug Toxicities

What are major side effect profiles that I should be aware of?

The following is not an inclusive list.

Neuro-Psychiatric

  • Aprimilast, Belimumab, and Broadlumab – worsening depression and suicidal ideation
  • Steroids can cause mood disorders
  • TNF-alpha inhibitors can cause demyelinating disorders

Ophthalmologic

  • Hydroxychloroquine – need to see ophthalmology annually while on this medication given retinal toxicity
  • Steroids – can cause glaucoma and cataracts

Cardiovascular/Thrombotic

  • Jak-Inhibitors have a black box warning for thrombosis and cardiovascular disease
  • IL-6 inhibitors can increase lipids
  • Steroids and NSAIDs can increase risk of CVD, HTN
  • Plaquenil can rarely cause cardiomyopathy

Pulmonology

  • MTX can causes interstitial pneumonitis
  • Orencia can worsen COPD exacerbations

Hepatic/Renal Toxicity

  • Hepatotoxic – methotrexate, leflunomide, NSAIDS, Imuran, IL-6 inhibitors
  • Several medications may affect the kidneys, or are renally dosed

Gastrointestinal

  • IL-6 inhibitors and Jak-inhibitors Gastrointestinal perforation
  • Steroids can cause PUD
  • NSAISD can use PUD and gastritis (COX-2 inhibitors have better tolerated GI side effects)
  • IL-17 inhibitors can worsen or cause inflammatory bowel disease

Infectious

  • Most of these medications need to be held when somebody has an acute infection or is on antibiotics. An exception to this rule is hydroxychloroquine which can be continued.
  • Consider these specific infections:
    • Hepatitis B reactivation – TNF-alpha inhibitors, rituximab
    • Latent tuberculosis reactivation – TNF-alpha inhibitors
    • Progressive multifocal leukoencephalopathy (PML) – rituximab
    • Herpes Zoster – belimumab, Jak Inhibitors
    • Pneumocystis pneumonia – steroids (consider PJP prophylaxis when indicated)
    • Meningococcemia – eculizimab

Hematology/Oncology

  • Cytopenia: Rituximab, methotrexate, sulfasalazine, leflunomide, mycophenolate, azathioprine, IL-1 inhibitors
  • Malignancy: methotrexate, azathioprine, mycophenolate, TNF-alpha inhibitors, cyclophosphamide

Endocrine

  • Steroids can cause hyperglycemia (diabetes), osteoporosis and adrenal insufficiency (consider Calcium/Vit D supplementation and screening DEXA)

Teratogenic

  • Cyclophosphamide, methotrexate, leflunomide, mycophenolate, thalidomide
View Guidelines for Pregnancy and Rheumatic Disease

Perioperative Concerns

Should you schedule elective surgeries for patients on rheumatology medications?

  • Hold most medications one dosing interval prior to surgery.
  • Hold for 2 weeks until wound healing.
  • Look at the guidelines for specific medications.

The ACR, together with the American Association of Hip and Knee Surgeons, have published a guideline on perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. 

View Guideline