Before starting

Required

• Baseline
  • Albumin
  • ALT or AST
  • Full blood count
  • Urinalysis
  • Urea and electrolytes
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate

After started or dose changed

Required

• Every 2 weeks for 6 weeks to 3 months, then monthly
  • Albumin
  • ALT or AST
  • Urinalysis
  • Full blood count
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate

Ongoing once stable

Required

• Monthly for 12 months; then every 3 months
  • Albumin
  • ALT or AST
  • Full blood count
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate · Increase to every 2 weeks if renal impairment
  • Urinalysis

Indications other than rheumatoid arthritis

Consider whether reducing monitoring frequency is possible in stable patients. For example, longer interval may be possible in cystinuria and Wilson’s disease.

Abnormal results

Monitor trends

Full blood count

Consider stopping and discussing with rheumatologist three successive falls in count for WBCs, neutrophils, platelets.

Respond to absolute values

Full blood count

Consider stopping and discussing if absolute values are:

• WBC less than 3.5 x 10⁹/L
• Neutrophils less than 1.6 x 10⁹/L
• Platelets less than 150 × 10⁹L

Stop permanently if recurrent leucopenia or thrombocytopenia.

Restart at reduced dose when counts return to reference range.

Proteinuria

If greater than 2, check mid-stream sample of urine:

• If evidence of infection, treat appropriately
• If sterile and persists, discuss with specialist.

Bruising or sore throat

Withhold until FBC available.

Care with elderly

Especially careful monitoring is necessary in the elderly since increased toxicity has been observed in this patient population regardless of renal function.

Abnormal results

Advice to patients

Advise patients to:

• Report presence of rash or oral ulceration. If severe or oral ulceration present withhold and discuss with specialist.
• Report sore throat, fever, infection, non-specific illness, unexpected bleeding and bruising, purpura.
• Beware that if hypersensitive to penicillin may react rarely to penicillamine.
• Alteration of taste may settle spontaneously.

Bibliography

• Ledingham J, Gullick N, Irving K et al. BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs, Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868 [cited June 2020)
• Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press [cited 19/06/2020]
• NICE Clinical Knowledge Summaries (CKS). DMARDs – penicillamine. Updated Jul 2018 [cited 30/07/2020]
• Mylan. Summary of Product Characteristics -Penicillamine 250mg Film-coated tablets.  Last revised 09/2020 [cited 08/08/2020]