Is it safe to start Disease-Modifying Antirheumatic Drugs (DMARDs) in a patient with low T cells, leukopenia (low White Blood Cell (WBC) count), anemia (low hemoglobin (Hgb) levels), and a slightly increased red blood cell count?

From the Guidelines

It is not safe to start DMARD therapy with low T cells, white blood cells, and hemoglobin, along with slightly elevated red blood cells, without first identifying and addressing the underlying cause. Starting a disease-modifying antirheumatic drug (DMARD) with these abnormal blood counts requires caution and medical supervision. The low white blood cell and T cell counts indicate potential immune system suppression, which is concerning because DMARDs like methotrexate, leflunomide, or biologics can further suppress your immune system and worsen cytopenias, as noted in the 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis 1. This could increase your risk of infections and other complications. The combination of low hemoglobin with elevated red blood cells is also unusual and warrants investigation.

Key Considerations

• The patient should undergo a complete evaluation by their rheumatologist or hematologist to determine the cause of the blood abnormalities, as suggested by the guidelines 1.
• Additional tests such as bone marrow examination, iron studies, or other specialized blood tests may be necessary before making treatment decisions.
• Once the cause is identified, the physician can determine if DMARD therapy is appropriate, possibly with dose adjustments, alternative medication choices, or concurrent treatments to address the blood abnormalities, considering the recommendations for DMARD initiation in patients with moderate-to-high disease activity 1.

Recommendations

• Methotrexate monotherapy is strongly recommended over other DMARDs for patients with moderate-to-high disease activity, but this should be considered in the context of the patient's overall health and blood count abnormalities 1.
• The decision to start DMARD therapy should be made on a case-by-case basis, taking into account the potential benefits and risks, as well as the patient's individual circumstances, as emphasized in the guidelines 1.

From the FDA Drug Label

Methotrexate can suppress hematopoiesis and cause anemia, aplastic anemia, pancytopenia, leukopenia, neutropenia, and/or thrombocytopenia. In patients with malignancy and preexisting hematopoietic impairment, the drug should be used with caution, if at all In psoriasis and rheumatoid arthritis, methotrexate should be stopped immediately if there is a significant drop in blood counts

The patient has low T cells, low WBC, low Hgb, and slightly increased red blood cells, indicating preexisting hematopoietic impairment. Given this, it is not safe to start DMARD (Disease-Modifying Antirheumatic Drug) such as methotrexate without caution.

• The patient's low blood cell counts suggest a potential risk for myelosuppression.
• Methotrexate should be used with extreme caution in patients with preexisting hematopoietic impairment.
• The decision to start methotrexate should be made with careful consideration of the potential benefits and risks, and the patient should be closely monitored for signs of hematologic toxicity 2.

From the Research

DMARD Therapy Considerations

• The decision to start DMARD therapy depends on various factors, including the patient's overall health, disease severity, and laboratory results 3.
• Low T cells, WBC, and Hgb, along with slightly increased red blood cells, may indicate a compromised immune system, which could be a concern when starting DMARD therapy 3.

Safety and Efficacy of DMARDs

• DMARDs have been shown to be effective in relieving pain and inhibiting disease progression in various arthritic conditions, including rheumatoid arthritis 3, 4, 5.
• Combination therapy with DMARDs, such as methotrexate, sulfasalazine, and hydroxychloroquine, has been found to be well-tolerated and associated with no significant increase in adverse events compared to monotherapy 4, 5.

Laboratory Results and DMARD Therapy

• There is no direct evidence in the provided studies that addresses the safety of starting DMARD therapy with low T cells, WBC, and Hgb, and slightly increased red blood cells 3, 4, 5.
• However, it is essential to consider the patient's laboratory results and overall health status when making decisions about DMARD therapy, as certain DMARDs may have adverse effects on the immune system or other organs 3.