Hospital Pharmacist
2008;15:215-216
June 2008

The role of the specialist pharmacist in rheumatology

By Richard Copeland, MPhil, MRPharmS

There are several rheumatology clinics at Northumbria Healthcare NHS Foundation trust. I have been working with the rheumatology team for two and a half years. This specialty allows me to use my skills as an independent prescriber, my recently acquired skills in administering intra-articular injections, and my developing skills in clinical assessment.

The clinics

On a typical day, I run two clinics (morning and afternoon) and see up to 24 patients. These patients will already have an established diagnosis, usually a long-term inflammatory arthropathy such as rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis, and will be regularly reviewed in the clinic, usually every six months.

Some patients will attend just a few appointments before their care is transferred back to their GP — these patients would generally have conditions such as gout or polymyalgia rheumatica.

Many patients will have co-existing osteoarthritis, plus a range of comorbidities, and will be taking a number of medicines.

The clinics are based in community hospitals, where we have good access to medical imaging (through the electronic picture archiving and communications system) and high resolution musculoskeletal ultrasound. My clinics run concurrently with the consultant rheumatologist’s clinics — the consultant was my mentor for both supplementary and independent prescribing. This arrangement also facilitates my continuing professional development both within rheumatology and as a prescriber.

A nurse specialist is also present. She usually sees her own cohort of patients, but I can refer patients to her to facilitate the initiation of parenteral methotrexate or anti-TNF therapy, for example.

I can also consult other members of the multidisciplinary team, who are often located nearby within the purpose-built area. Often, the clinics will also be attended by trainees, including specialist registrars in rheumatology, integrated general practice registrars, foundation doctors and medical students.

Assessment

At the clinic I assess each patient’s joint function and degree of inflammation, in addition to their general capability of undertaking daily tasks at work and at home. I look for the presence of synovitis (inflammation of the membranes that line the joints) and, if present, I assess the severity.

Ultrasound assessment by the consultant is available if required for difficult cases — this is a sensitive technique that can accurately identify when synovitis is present, but it requires specific training. Such clinical examination can help determine whether the patient has benefited from treatment with disease modifying antirheumatic drugs (DMARDs).

I can also request X-rays of specific joints, and request additional or repeat blood tests (eg, for rheumatoid factor) if this will aid continued management.

Prescribing

My qualification as an independent prescriber allows me to initiate or alter therapy as appropriate. Doses of DMARDs may be altered according to efficacy, toxicity and tolerability, or an alternative or additional DMARD may be prescribed.

Several factors are considered when tailoring DMARD treatment. These include:

• Whether the drugs and doses are tolerated

• The requirement for use of non-steroidal anti-inflammatory drugs and other analgesics

• The relative stability of blood monitoring parameters, including haemoglobin, white blood cell counts, liver and renal function, and the inflammatory markers (erythrocyte sedimentation rate and C-reactive protein)

• How happy the patient is with his or her current treatment

Patients with active disease may have widespread inflammation in many joints, and may benefit from the administration of intramuscular corticosteroids. I prescribe these and record it in the patient’s notes for subsequent administration by a nurse at the clinic.

Patients who have failed to respond adequately to DMARD treatment, or who have been intolerant of at least two DMARDs, may be considered for anti-tumour necrosis factor-alpha treatment. These patients may be referred to the nurse specialist for assessment of disease activity.

National Institute for Health and Clinical Excellence guidance on this treatment states that two disease activity assessments must be undertaken, one month apart, and that infection risk (especially tuberculosis) should be considered (see Special Feature, p208 (PDF 60K)).

Intra-articular injections

Patients requiring intramuscular injections of corticosteroids have them administered by the clinic nurses, but administration of intra-articular injections requires specific training which non-specialist nurses will not have. I have undertaken training in this procedure so that I can administer the injections myself rather than having to request administration from the consultant or specialist registrar.

It may appear challenging for a pharmacist to administer intra-articular injections since pharmacists do not typically perform invasive procedures. However, in terms of continuity of care it makes sense for me to treat the patients I have assessed.

The intra-articular injections course I attended last year is run by my mentor and designed primarily for GPs. Competence is demonstrated by injecting synthetic model joints, followed by supervised patient injections. This required the development of a new skill set, given that I had never previously administered any form of injection.

However, my knowledge of the aseptic preparation and administration of injections was a good basis for development.

Patient information

It is important that patients are given both verbal and written information regarding their disease and its treatment, and have the opportunity to ask questions and make informed choices. This is especially important with respect to the potential risks and benefits of drug treatment.

In addition to verbal information, information leaflets produced by the Arthritis Research Campaign are routinely used in clinic. I have also been invited to contribute to the regular patient education groups for those with newly diagnosed inflammatory arthritis.

Multidisciplinary team

An integral part of rheumatology practice is the identification of problems which may benefit from referral to other members of the team. Patients may benefit from exercise and pain management programmes devised by a physiotherapist; hand or wrist splints provided by an occupational therapist; or tailored footwear provided by a podiatrist.

The pharmacist’s contribution to patient care in rheumatology was initially evaluated by team members in 2006 during an evaluation of supplementary prescribing.¹

A high level of satisfaction with my involvement was reported. Comments from respondents include:

• “There is an obvious benefit to both parties involved, both pharmacist and doctor”

• “… objective consultative role in prescribing that cannot be provided by drug reps”

• “There is a place for a pharmacist on the rheumatology team because it can benefit the patients with side effects, and give them a choice of treatment”

The results of this survey were presented at the most recent British Society for Rheumatology annual general meeting, where there was genuine interest in my role.

Further evaluation led to us establishing the business case for continued funding of my role. Factors considered included the rate of pay for my role, follow-up work (see below), input to the multidisciplinary team and therapeutics meetings, numbers of patients seen and income for the trust under payment by results.

We have also received anecdotal feedback suggesting that patients are also satisfied with the service they receive from the doctors, nurse specialists and myself. We are currently completing a large patient survey to confirm this.

Follow-up work

The majority of questions asked by clinic patients can be answered directly, or may require a brief internet search. However, some require a more extensive search. In this case, I will contact patients by telephone or letter when I have obtained and evaluated the information.

All patients are offered copies of the clinic letter that is sent to their GP — local audit work has shown that this improves communication and understanding and is valued by the patients. The letters are produced by secretaries using a dictating machine. It is dictated in front of each patient, to re-enforce messages about treatment decisions, and to enable the patient to correct any information which is not accurate, such as an incorrect address, or any information regarding their disease state or treatment.

Therapeutics meetings

Regular meetings are held with the rheumatology consultant, specialist registrars, specialist nurses and myself, to discuss patients who may be eligible for anti-TNF treatment. As a minimum, such patients have to meet NICE criteria, and alternative treatment approaches are also discussed. This might include the use of subcutaneous methotrexate to replace oral treatment, or combination DMARD treatment (eg, triple therapy with methotrexate, sulfasalazine and hydroxychloroquine).

Conclusion

The position of specialist pharmacist in rheumatology can be developed successfully within the multidisciplinary team. The use of developing and innovative roles, including prescribing and monitoring of DMARDs, and administration of intra-articular injections, will help in the continued establishment of such posts.

Acknowledgements Fraser Birrell, consultant rheumatologist at Northumbria Heathcare NHS Foundation Trust for his help with writing this article.

References

1. Copeland R, Birrell FN. Is a supplementary prescriber a useful supplement to the rheumatology team? Rheumatology 2007;47 (suppl 1):i150.