Section 1: Current Systemic Medication for Inflammatory Disease

______MANCHESTER UVEITIS CLINIC

HEALTH REVIEW ______

Surname: Review date: Patient Forename: Label Uveitis Diagnosis: Hosp. No: Systemic Diagnosis:

Section 1: Current Systemic medication for Inflammatory Disease

Drug, Current dose Date started Treatment duration Complete sections: (m) Prednisolone 2, 3, 4, 10 Azathioprine 2, 6, 8, 9

Ciclosporin 2, 7, 8, 9, 10

Methotrexate 2, 5, 8 Mycophenolate 2, 6, 8, 9 Tacrolimus 2, 7, 8, 9, 10 Other...... Discontinued (circle): AZA CYC MTX MYC TAC

Section 2: Identify other medication which may cause interactions

NSAID (Cyc,Tac ) Rifampicin (Cyc,Tac,Pred ) Allopurinol (Aza) Comment:

1 NB Risk of peptic ulcer Isoniazid (Cyc,Tac ) Indomethacin (Aza)

if also on Prednisolone Phenytoin (Cyc,Tac ) Septrin (Aza)

Verapamil (Cyc,Tac ) Carbamazepine (Cyc,Tac ) Aciclovir (Myc)

Nicardipine (Cyc,Tac ) Sulphadiazine (Cyc,Tac ) Antacids (Myc)

Nifedipine (Cyc,Tac ) Antifungals (Cyc,Tac ) Diltiazem (Cyc,Tac )

Section 3: Prednisolone (Ref GF1 Protocol; Prednisolone)

Current weight: Starting weight: Weight gain:

Assess symptoms & examine: Comments: Action required:

Bruising tendency? Y N Skin striae? Y N Hirsute/Cushingoid? Y N

Dyspepsia? Y N On H2 antagonist?: On PPI?: Other? (Specify):

Section 4: Bone Health (Ref GF1 Protocol; Prednisolone)

Risk Factor Assessment Action required:

Smoker? Y N ...... cigs/day or...... Alcohol intake? ...... units/wk

 Periods irregular? Y N Comment: Past amenorrhoea? Y N Oophorectomy? Y N On HRT? Y N Post-menopausal? Y N Preg on treatment? Y N

Past anorexia/Vegan? Y N Comment: Weight-bearing exercise? ...... miles/wk or......

Arthritis? Y N Limits mobility? Y N

2 Diabetic? Y N Duration ...... yrs Other ?......

Bone density assessments DEXA first date: / / T-score Lumbar spine ...... T-score Femoral neck ...... DEXA last date: / / T-score Lumbar spine ...... T-score Femoral neck ...... Next DEXA due? Action taken: Prophylaxis

Calcichew D3F? Y N Dose...... Duration...... Action: Didronel PMO? Y N Dose...... Duration...... Action: Fosamax? Y N Dose...... Duration...... Action: Supervision

c/o Uveitis Clinic only? Y N c/o Dr Davies Dr Selby Action:

Section 5: Methotrexate (Ref GF1 Protocol: Methotrexate)

Adverse symptoms and safety checks Action taken

Stomatitis, ulcers? Y N Current Folate dose: Advise no NSAID, no alcohol

GIT pain, diarrhoea? Y N Using contraception?  Y N

Cough, chest pain? Y N Other (specify): Assess blood profile within last 3 months Action taken

Abnormal liver function? Y N Abnormal WCC? Y N

Anaemia? Y N Abnormal Platelets? Y N

Section 6: Azathioprine (Ref GF1 Protocol: Azathioprine) Mycophenolate mofetil (Ref GF1 Protocol: Mycophenolate)

Bruising, gum bleeding? Y N Using contraception?  Y N

GIT symptoms? Y N Hair loss? Y N Other (specify):

3 Assess blood profile within last 3 months Action taken

Abnormal liver function? Y N Lymphocyte count:

Anaemia? Y N Macrocytosis? Y N

Section 7: Ciclosporin (Ref GF1 Protocol: Ciclosporin) Tacrolimus (Ref GF1 Protocol: Tacrolimus)

Tremor, paraesthesiae, cramps, Using contraception?  Y N Advise no NSAID other neuro symptoms? Y N

Hair: excess? (Cyc) Y N Gum disease/caries? Y N Hair loss? (Tac) Y N Dental hygience/checks? Y N

GIT symptoms? Y N Other (specify): Assess blood profile within last 3 months Action taken

Normal liver function? Y N WCC normal? Y N

Anaemia? Y N Hyperglycaemia? (Tac) Y N Creatinine Before: Creatinine Now :

Section 8: Infection (Ref GF1 Protocols: Azathioprine, Cyclosporin, Mycophenolate, Tacrolimus)

Infections since last review, and comments Action required:

Thrush? Y N Warts? Y N

Hospital admission? Y N Other? (Specify) How many antibiotic courses in last year? Immunisation and infection history

Definite chickenpox? Y N VZV serology +ve -ve

Measles immunised? Y N BCG immunised? Y N

TB history? Y N On Septrin prophylaxis? Y N

Section 9: Malignancy (Ref GF1 Protocols: Azathioprine, Cyclosporin, Mycophenolate, Tacrolimus)

4 Self-examination Suspicious lesions Action taken

 Regular breast examination? Y N Inform NPJ. Comment: Give pamphlet

 Skin self- examination? Y N “immunosuppression and

 Glands neck/axilla/groin? Y N skin cancer” Other?:

Section 10: Cardiovascular (Ref GF1 Protocol: Cardiovascular Disease)

Assessment of cardiovascular risk 1. Blood pressure - measure BP today / Average last 3 BPs = / (On antihypertensive? 1. 2. Specify): 2. Lipid profile - blood taken Total cholesterol (TC) = Ratio TC/HDL = HDL = (On statin? Specify):

3. Diabetes - urinalysis/history IDDM NIDDM Diabetic Y N (On treatment? Specify):

4. Smoking Smoker Y N 5. Assess coronary risk Use Charts 2 & 3 Low / Moderate / High Body mass index (Chart 1) Height...... Weight...... OK / Obese / Severe obese Additional risks?: Alcohol intake >28 units/wk Y N Sedentary Y N Action taken: New treatment required: informed of: GP to be