Primary Care Pharmacy March 2000 Vol 1 No 2 p40-43
Disease management
Rheumatoid arthritis - How to establish a pharmacist-led clinic
By Alison Wilson MSc, MRPharmS
This article aims to provide the background knowledge needed to help establish a pharmacist-led clinic in primary care. It places particular emphasis on dealing with patients receiving repeat prescriptions for DMARDs
Rheumatoid arthritis (RA) is a common disease affecting between 1 and 3 per cent of the population, and perhaps as many as 5 per cent of women over the age of 65 years.1 The disease is an important cause of disability, morbidity and mortality. Life expectancy is reduced by approximately four years in men and by about 10 years in women.2 Disease onset is most common in the fourth and fifth decades and is more common in women than men, with a 3:1 preponderance. It is a multisystem, chronic inflammatory condition, which predominantly affects synovial joints.
The disease is of unknown aetiology. RA usually presents with painful swollen joints which, in the majority of patients, progress to joint erosions and gradual cartilage and bone destruction. It is this destructive process that leads to the increased morbidity and mortality in RA patients. Important extra-articular features also occur in RA and include anaemia of chronic disease, muscle wasting, osteoporosis, eye and skin problems, Raynaud's phenomenon and vasculitis.
RA cannot be adequately managed by one specialist in isolation from others - a multidisciplinary team is required.3 Specialist rheumatology nurses have become well established in many hospitals and have enhanced patient satisfaction with their care.4,5 The role of these nurses includes monitoring drugs used to treat RA, providing advice and support, and patient education. Patient education is an important aspect of treatment. Although only about one-fourth as effective as non-steroidal anti-inflammatory drugs (NSAIDs) for reducing pain, and about half as effective for reducing disability, the improvement achieved by educational programmes is clinically significant.6 Understanding the disease may help sufferers cope better and have realistic expectations of treatment outcomes.
Treatment of RA
The goals of treatment of RA are listed in Panel 1. Drugs are only part of the treatment of RA. Appropriate exercise programmes under the supervision of a physiotherapist are essential to maintain mobility and prevent deformities from developing. In addition, surgery has an important role, with joint replacement becoming increasingly common. Any management plan should be tailored for each individual. Most patients' treatment revolves around the use of various combinations of NSAIDs, disease modifying anti-rheumatic drugs (DMARDs) and corticosteroids. NSAIDs can provide pain relief but have no effect on disease progression. The DMARDs are more effective at reducing pain and swelling but have a slower onset of action. They can produce an improvement in the biochemical markers of disease activity but, in long-term studies, their ability to prevent joint destruction has been disappointing. Corticosteroids can also improve symptomatic relief but their long-term use has gone out of favour owing to their undesirable side effect profile.
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Panel 1 Goals of treatment in rheumatoid arthritis3
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Setting up the service
Prior to establishing the clinic, it is important to communicate with other members of the multidisciplinary team that might deal with RA patients in both primary and secondary care. It is worth observing a consultant's and/or a rheumatology nurse's clinic to see what situations are likely to arise and to note how these health care professionals deal with them. A detailed protocol must be made available defining the roles and responsibilities of the pharmacist. This should include details of methods of patient referral, how the clinic will operate, clinical guidelines being used for decision making, dealing with abnormal results, patient information leaflets and telephone numbers of specialist centres. The protocol should include a detailed monograph on all the drugs being monitored, with information on licensed indications, precautions and contra-indications of drugs used, their potential drug interactions, dose schedules, full monitoring details and frequency of monitoring. It should also cover what to do during illness, advice for dealing with abnormal results and adverse events, and patient information leaflets.
A patient counselling checklist (Panel 2) and a summary sheet on managing adverse events can be a useful inclusion in the protocol. Most areas or regions have their own monitoring guidelines and, when writing the practice protocol, it is worth considering guidelines from different sources and discussing them with the local specialist. In some guidelines, the frequency of monitoring will not be the same as that indicated on the product licence and this should be borne in mind when writing the protocol.
Panel 2: Patient counselling checklist |
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| Introduction | |
| Check that you have the correct patient and address is correct | |
| Information | |
| What drug is the patient taking? | Name of drug |
| Strength of tablets | |
| What the drug does? | Include side effects |
| Why it is needed | |
| For how long is it needed? | Explain the length of treatment required |
| How much is needed? | Review dose with blood tests |
| When should it be taken? | Time of day/week or before/after food |
| What to do if a dose is missed | Never double doses |
| Blood/urine test arrangements | GP instead of hospital (hospital review once or twice a year) |
| Effect of other medicines | Always ask before buying anything |
| What about present medicines? | Current drug history |
| Diet | Normal diet |
| Alcohol | Avoid alcohol with methotrexate |
| Illness | |
| Information card | |
| Pregnancy | |
| Summary | |
| Ask for questions, make sure dose and time, side effects, drugs are known | |
| Patient information leaflet provided | Yes / No |
Patient identification
All patients receiving repeat prescriptions for DMARDs can be identified from practice computer systems by searching under drug names. Although this article refers to RA, conducting a search under drug names will also identify those patients receiving DMARDs for other indications, such as dermatology, Crohn's disease and ulcerative colitis, other inflammatory conditions or organ transplant. Thus, depending on patient numbers, it may be more practical to run a clinic for all patients on DMARDs and adapt the monitoring criteria to that recommended for each disease. However, the remainder of this article will focus on RA.
Once patients have been identified, a register can be created containing relevant information from the computer records and medical notes. Patients can then be invited to attend the clinic. It is important that the patients are given full information relating to the purpose and nature of the clinic and are given the opportunity to elect for the standard method of care in the practice.12
Data collection form
A well-constructed data collection form will enhance the running of the clinic. It is worth piloting a form prior to full use. On some practice computer systems it may be possible to construct an individualised template for the clinic. The data collection form should include the following details:
- Date of diagnosis of RA
- Full drug history, including dose and duration of current and past treatments, response to treatment and use of alternative/homoeopathic remedies
- Compliance/frequency of prescription requests (available from computerised repeat prescription records)
- Ability to administer medicines and any compliance aids required
- Allergies and/or intolerance to drugs and adverse drug reactions
- Pain control
- Investigations and results
- Concurrent disease history
- Activities of daily living
- How the patient was previously reviewed (ie, practice nurse or hospital out patient) and frequency of review
- Information obtained from the patient, including knowledge and perception of therapy
Running the clinic
Prior to running the clinic, pharmacists must decide who will take the blood samples needed for monitoring DMARD therapy. Current practice is that a nurse takes blood and a doctor reviews the results. The patient may then see the doctor personally for the result, phone the surgery for the result or assume it is normal and wait for the surgery to contact them if it is not. An alternative would be for the pharmacist to run a clinic with the nurse taking the samples or for the pharmacist to take the blood themselves. Arrangements should be made for blood samples to be analysed the same day. Clinics should be run at regular intervals and at a frequency to suit the number of patients attending. A suitable appointment time is 15 minutes. Patients should be reviewed in a systematic manner, with relevant outcomes documented in the their medical notes or computer record.
During each clinic appointment the pharmacists should review the following with each patient:
- Previous blood results
- Changes to drug therapy
- Side effects of therapy
- Compliance and ability to administer medicines
- Pain control and analgesic use
- Changes in diet and exercise
- Use of over-the-counter medicines and alternative remedies
- Activities of daily living
Patients may also receive further education and counselling from the pharmacist, if required. Safety can be maximised with the provision of a patient-held monitoring card to record any results. If dose changes are required, these should be made according to the agreed protocol or the patient should be referred to the GP or specialist. It is important that patients are in agreement with any proposed change to treatment. Abnormal results, or other problems with treatment identified during the pharmacist's consultation, must be discussed with the patient's GP or specialist in the first instance.
Monitoring
Typical monitoring parameters are shown in Table 1.11,13,15 As previously mentioned, these may vary according to local guidelines. In addition to the monitoring required for each drug, tests for inflammation are necessary. This might include determination of the erythrocyte sedimentation rate, C-reactive protein and plasma viscosity. Laboratory findings in RA are summarised in Table 2.2 Each test measures different components of the acute phase of the inflammatory response and may be used as a reasonable guide to the success of treatment. However, it should be borne in mind that they are not specific to RA. In addition, tests for markers of inflammation vary between laboratories, so check what is available with the local laboratory first. The activity of RA can be assessed in a number of other ways (Table 3).14
Table 1 Monitoring of patients on DMARDs |
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| Drug | Parameter | Schedule |
| Sulphasalazine | FBC | Baseline, then fortnightly for 2 months, monthly for 3 months, then 3 monthly |
| RF | Baseline | |
| LFT | Baseline, then fortnightly for 2 months, monthly for 3 months, then 3 monthly | |
| Methotrexate | FBC | Baseline, then fortnightly for 2 months, then monthly |
| RF | Baseline | |
| LFT | Baseline, then fortnightly for 2 months, then, monthly | |
| CXR | Baseline | |
| Azathioprine | FBC | Baseline, then fortnightly for 2 months, monthly for 3 months, then 3 monthly |
| RF | Baseline | |
| LFT | Baseline, then fortnightly for 2 months, monthly for 3 months, then 3 monthly | |
| D-penicillamine | FBC | Baseline, then fortnightly for 2 months or when changing doses, then every 1-3 months |
| RF | Baseline | |
| U | Baseline, then fortnightly for 2 months or when changing doses, then every 1-3 months | |
| Parenteral gold | FBC | Prior to each injection |
| RF | Baseline | |
| U | Prior to each injection | |
| LFT | Baseline | |
| Cyclosporin | BP | Baseline, fortnightly for 2 months, then monthly |
| RF | Baseline, fortnightly for 2 months, then monthly | |
| LFT | Monitor regularly if co-administering NSAID | |
| U | Baseline, fortnightly for 2 months, then monthly | |
| Hydroxychloroquine | Eye | Baseline, data sheet recommends 3-6 monthly |
| Key: FBC = full blood count (haemoglobin, white cell count, platelets), RF = renal function (serum creatinine, urea, electrolytes), LFT = liver function test (alkaline phosphatase, gamma-glutamyltransferase, alanine/aspartate aminotransferase), U = urinalysis for blood and protein, BP = blood pressure, CXR = chest X-ray. | ||
Table 2 Laboratory findings in RA2
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Table 3 Means of assessing disease activity in RA14
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Summary
There is much scope for a pharmacist-led DMARD clinic in primary care. Successful management of rheumatic disease requires careful assessment of the disease in the context of the whole person. The practice pharmacist is in an ideal position, as a member of the multidisciplinary health care team, to help with the successful management of such patients. The pharmacist's contribution to the team will help to ensure that safe and efficient systems are in place for all patients receiving repeat prescriptions for DMARDs.