What are major side effect profiles that I should be aware of?
(The following is not an inclusive list. Additionally, many of these side effects occur uncommonly, except when noted.)
Neuro-Psychiatric
- Apremilast, belimumab, and brodalumab – worsening depression and suicidal ideation
- Steroids can cause mood disorders (common)
- 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 – both LDL and HDL (common)
- Steroids and NSAIDs can increase risk of CVD, HTN
- Hydroxychloroquine can rarely cause cardiomyopathy
Pulmonology
- Methotrexate can causes interstitial pneumonitis
- Abatacept can worsen COPD exacerbations
Hepatic/Renal Toxicity
- Hepatotoxic – methotrexate, leflunomide, NSAIDs, azathioprine, IL-6 inhibitors (common)
- Several medications may affect the kidneys, or are renally dosed (common)
Gastrointestinal
- IL-6 inhibitors and JAK inhibitors gastrointestinal perforation
- Steroids can cause PUD (common)
- NSAIDs can use PUD and gastritis; COX-2 inhibitors have better tolerated GI side effects (common)
- 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 (particularly skin cancers): Methotrexate, azathioprine, mycophenolate, TNF-alpha inhibitors, cyclophosphamide
Endocrine
- Steroids can cause hyperglycemia (diabetes), osteoporosis, and adrenal insufficiency; consider calcium/vitamin D supplementation and screening DEXA (common)
Teratogenic
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.