Transcript DMARD Shared Care Guidelines

DMARD Shared Care
Guidelines
Sam Thomson
8/9/2010
DMARDS
DMARDs
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Azathioprine = 6 Mercaptopurine
Ciclosporin
Sodium Aurothiomalate = Myocrisin = Gold
Hydroxychloroquine
Leflunomide
Methotrexate
Penicillamine
Sulfasalazine
JAPC Shared Care Agreement
 Derbyshire Joint Area Prescribing
Committee
 Based on British Society of Rheumatology
Guidelines
Introduction
 Due to the potentially serious side-effects that
Disease Modifying Anti-Rheumatic Drugs
(DMARDs) can occasionally cause, regular blood
monitoring is necessary.
 In Derbyshire DMARDs are classified as AMBER
drugs i.e. considered suitable for GP prescribing
following specialist initiation of therapy and patient
stabilisation, with specific long term monitoring for
toxicity needing ongoing specialist support.
 The concept of drugs that GPs would not
routinely initiate and therefore would not
normally be familiar with is encompassed in
Dept. of Health EL(91)127 “Responsibility
for prescribing between Hospitals and GPs”.
Referral Criteria
 Shared Care is only appropriate if it
provides the optimum solution for the
patient.
 Prescribing responsibility will only be
transferred when it is agreed by the
consultant and the patient’s GP that the
patient’s condition is stable or predictable.
Referral Criteria
 Safe prescribing must be accompanied by
effective monitoring
 Patients will only be referred to the GP once
the GP has agreed in each individual case.
 Once stable the patient will be given a
supply of Methotrexate sufficient for 4 weeks
maintenance therapy.
Three Areas of Responsibility
 GP
 Consultant
 Patient
GP
1. Ensure compatibility with other
concomitant medication.
2. Prescribe the dose and formulation
recommended.
3. Monitor FBC, U&E, creatinine, LFTs at
recommended frequencies and refer if
abnormal.
4. Adjust the dose as advised by the
specialist.
GP
5. Stop treatment on the advice of the
specialist or immediately if any urgent need
to stop treatment arises.
6. Report adverse events to the specialist and
CSM.
7. Update the patient’s methotrexate booklet
8. Always prescribe oral methotrexate using
multiples of the 2.5mg strength tablet,
AVOID USING THE 10mg STRENGTH.
Consultant
1. Discuss the possible benefits and side
effects of treatment with the patient.
2. Perform baseline tests (FBC, U&E, & LFT,
CXR. PFTs may be undertaken in some
patients
3. Provide results of baseline tests
4. Prescribe methotrexate for the first month
or until the patient is stable.
5. Recommend dose of the drug and
frequency of monitoring.
Consultant
6. Periodically review the patient and advise the
GP promptly on when to adjust the dose, stop
treatment or consult with the specialist.
7. Ensure that clear backup arrangements exist for
GPs to obtain advice and support.
8. Report adverse events to the CSM and GP.
9. Provide the patient with the NPSA hand held
methotrexate booklet
10. Where parenteral methotrexate is used ensure
that the patient is trained and able to administer
their methotrexate injections or alternative
appropriate arrangements for administration are
in place
Patient
1. Report to the specialist or GP if there is not a clear
understanding of the treatment and share any
concerns in relation to treatment.
2. Inform specialist or GP of any other medication
being taken including over-the-counter products.
3. Report any adverse effects or warning symptoms
to the specialist or GP whilst taking the drug.
4. Carry and present their methotrexate booklet to
their GP and community pharmacy at each
prescribing and dispensing activity
Local Enhanced Services - LES
Or how the GP gets paid!
 Standard A – Specialist/Clinic interprets
bloods & physical monitoring and advises
GP is safe to continue to prescribe with any
changes to prescription of DMARD
 £6.50 per patient per year
LES
 Standard B – GP interprets bloods &
physical monitoring as per shared care
protocol to determine if safe to prescribe. If
out of range to contact specialist for advice
and make changes to DMARD as
instructed
 Fees - £30.00 per patient as a one off
administration fee
- £5.00 a month per patient on the
register
GP Tasks
 Keep a register of patients
 Evidence of robust, systematic and
responsive recall system for monitoring and
review as laid down in the shared care
guideline
 Mechanisms to deal with non-attendees
BSR Guidelines
General Advice
 Beware drug interactions
 Review individual monitoring protocols
when dose changes are implemented
 Patients should not receive immunisation
with live vaccines
 Beware infections treat vigorously - check
FBC and U&E
General Advice
 Beware oral ulceration, sorethroats,
nosebleeds, bruising, rash
 If patients come into close contact with
Herpes Zoster, consider passive
immunisation
 If BP >140/90 manage hypertension
according to NICE Hypertension Guidance
Frequency of Monitoring
 See quick reference guide for specifics
 Any discretionary reduction in the frequency
of monitoring should only be on the
instruction of a Rheumatology specialist
 Enter result in patient-held record book
Withhold treatment & liaise with
Specialist if: Severe rash or bruising or ulceration of
mucous membranes.
 Any unexplained illness occurs including
nausea or diarrhoea
 If urinary protein on dipstick is 2+ send a
MSU for culture. If MSU confirms infection,
treat appropriately. If sterile proteinuria –
seek advice
Seek Help If :
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WCC falls <3.5 x 109/l
Neutrophils <2.0 x 109/l
Eosinophils >0.5 x 109/l
Platelet count falls below <150 x 109/l
MCV > 105 f/l
Creatinine >30% of baseline
LFTs (ALT or AST) increase > 2 fold rise above
upper limit reference range (Leflunomide special
rules – see above and full text)
Who to contact
 In hours, Rheumatology helpline
- 01332 787710
Out of hours, On call Pharmacist
- 01332 340131 bleep 1395
Websites