Making methotrexate provision safer
| One primary care trust has adopted
a new way to provide methotrexate in an effort to increase patient
safety. Naomi Kempner reports |
Naomi Kempner is a freelance
writer
|
In July 2000, Cambridgeshire Health Authority published an inquiry into
the death of a patient from methotrexate toxicity. The report describes
a catalogue of errors in which the patient took methotrexate 10mg daily
instead of weekly for rheumatoid arthritis, even after having been admitted
to hospital with signs of toxicity. The patient died in April, 2000.
About Knowsley PCT
• One of 40 second-wave sites of the medicines management services
collaborative.
• Situated in Kirkby, North East Liverpool, with a population of 123,000
• There are 40 GP practices, many of them single-handed or with only
two GPs
• Prescribing support team with one prescribing adviser, 4.6 WTE pharmacists
and 2.5 WTE technicians
• Other:
1. Removal of GTN sprays from patients’ repeat prescription,
making them a ‘repeatable acute’ to reduce waste
2. Medication review
initiative
3. Synchronisation scheme
4. Pharmacy intervention scheme — now
incorporating in-depth reviews in specific therapeutic areas |
The incident alerted health providers to the dangers of methotrexate
overdose. But it was not an isolated event. A report published this summer
by the National Patient Safety Agency identified 25 patient deaths and
26 cases of serious harm linked to the use of methotrexate in a community
setting over a 10-year period.
At the same time Birmingham researchers showed that rheumatology patients
had poor knowledge of their methotrexate therapy, which could leave them “vulnerable
to adverse effects from prescribing, dispensing or administration errors”.
Both the researchers and the Cambridgeshire inquiry questioned the need
for 10mg methotrexate tablets. However, a letter to The Pharmaceutical
Journal describes how not providing 10mg tablets can lead to confusion
if there is a discrepancy between hospital and community pharmacy stock
(14 December 2002).
The letter describes how a patient discharged from hospital on a dose
of methotrexate 10mg once a week was directed to take four 2.5mg tablets.
The repeat prescription from the GP called for methotrexate 10mg tablets
with an instruction to “take as directed”. This resulted
in the patient taking four of the higher strength tablets.
Staff at Knowsley PCT, Lancashire, were aware of these pitfalls when
they decided to make a blanket switch to 2.5mg tablets, effective across
both acute and primary care trusts. Although this may be a small change
in terms of medicines management, the PCT team hope it will reduce the
risk of confusion.
The trust’s medicines management facilitator Jaqueline Byrne explained
how the switch was achieved using a step by step approach.
The team contacted GPs, practice managers, pharmacists and patients with
information about the change. Notices were put in patient waiting areas
in surgeries and health centres. Guidelines for the switch are shown
the panel below.
Guidance on methotrexate switching from 10mg to 2.5mg tablets
GPs
• All methotrexate patients should be identified and any changes
necessary made in both computer and hard copy records
• A general letter should be sent to all patients taking methotrexate
explaining the new guidance
• A further letter should be attached to the notes explaining any
changes made, and given to the patient with the next prescription
• If possible, patients on doses of 10mg or more should be telephoned
to discuss possible changes with them
Community pharmacists
• All prescriptions for methotrexate should be dispensed with 2.5mg
tablets only
• Community pharmacists should identify methotrexate patients on
PMRs and liaise with GPs to ensure changes are made to prescriptions
• Patients should be counselled about changes made
• A standard leaflet should be put inside the prescription bag
• In rare cases where a patient is taking a high dose of methotrexate
and may be confused about counting out a large number of tablets
pharmacists could consider dispensing individual weekly doses
Patients
• It is vital that patients are informed of changes to procedures
• They should receive an initial letter from the practice and a
further letter with the next repeat prescription
• They should receive a leaflet in the prescription bag and be
counselled by the community pharmacist
• Where possible, patients on doses of 10mg or more should be telephoned
by the surgery to discuss changes
• All GP practice staff and community pharmacy staff should be
aware of the guidance and verbally reinforce advice to patients
Prescribing
• All prescriptions should have full directions, including which
day of the week medication is to be taken
• Quantities should be written in multiples of 2.5mg i.e for 10mg,
write 4 x 2.5mg |
Implementation of the changes started in May and was completed by September.
Community pharmacists were advised early on to enable them to run down
their stocks of 10mg tablets. Reimbursement for remaining stock was negotiated
with the LPC.
Ms Byrne says that a “manageable” number of surgeries in
the trust allowed primary care pharmacists and technicians to visit all
practices requesting help. In many cases the PCT team searched out patients
on practice computers and effected the changes.
Surprisingly Ms Byrne says that there has been no negative feedback on
the scheme so far by either patients or doctors. Even a dose of 15mg
weekly would amount to only six 2.5mg tablets. Unlike the findings of
the Birmingham researchers, she believes many RA patients to be aware
of the dangers of methotrexate.
Pharmaceutical adviser Lis Bennett says that the trust intends to check
on EPACT to find out how well the blanket ban has been implemented. |
