On Tuesday mornings, we have departmental x-ray meetings which look at relevant x-rays for patients under the care of rheumatology. As a pharmacist, interpreting x-rays is something I have always found difficult and therefore embrace any opportunity to learn and progress with these.
After the meeting, I usually schedule a time to pop into rheumatology daycare and touch base with the nurses there. We have a designated daycare for rheumatology patients where they can receive infusions of biologics such as infliximab or tocilizumab and be monitored for any infusion-related reactions. As biologics are such complex molecules, they have the potential to cause inflammatory and allergic reactions even months after patients have started treatment. Therefore, we always ensure we have the relevant medications on board in case of any medical emergency.
All infusions prescribed for patients are clinically screened by a pharmacist ensuring they are safe in terms of dose, blood biochemistry and indication. The screening, supply and dispensing to the unit is done two weeks in advance of patients due in to allow for timely dispensing. We have reduced wastage of high-cost drugs by training nurses to reconstitute drugs on the ward rather than using aseptically prepared bags. Clinical screening of daycare drug charts is the responsibility of the junior pharmacist currently rotated into rheumatology. This gives the juniors an opportunity to learn about biologics at an early stage of their career. We have guidelines and protocols and screening guides they can follow and of course, they can always refer to me for help if need be.
When pharmacists clinically screen prescriptions for biologics, there are several blood parameters we check. This includes ensuring the patient is not neutropenic or suffering from thrombocytopenia, HIV, TB, Hepatitis B/C results are negative and lipid profiles are normal.
As a Trust, we have good guidelines I have helped to develop to ensure all relevant tests are conducted as soon as a patient is identified as needing biologic treatment. However, in the chaos of a very busy department, it is vital to always double check, hence our pharmacy clinical check acts as a safety net.
As the clinical screening for supply is done by the rotational pharmacist, I ensure I approve and screen the funding requests which are done before prescribing. In doing this, I check the drug applied for is the most appropriate for the patient, factoring in co-morbidities, past infections, history of cancer and compliance.
Next, I have a meeting with my pre-registration trainee who has just started his training year. I have been a pre-registration tutor for the last 4 years and find it an enjoyable part of my job. I take pride in being a role model and shaping the future generation of the pharmacy workforce. I check he is settling into the hospital role ok and answer any questions he has. We make a plan to meet regularly and I remind him of my open-door policy.
My task for this afternoon is reviewing a service level agreement (SLA) between the trust and a homecare provider for a new drug. Sarilumab is available for the treatment of severe rheumatoid arthritis when disease activity is not controlled. In order for the Trust to prescribe it for our patients, I need to organise the drugs supply through one of our homecare providers. With high-cost drugs, many trusts use homecare as a means of saving money through VAT free schemes.
I have my own personal views on homecare but don’t think this is the most appropriate platform to discuss them. The SLA sets out the service provided, dispensing, billing, invoicing and supply of the drug. I, therefore, ensure that this is in-line with the needs of our service and is sufficient for the Trust and patient.
Food for thought… how far should we be pushing the boundaries with extended roles of pharmacists?
Kalveer Flora is Lead Rheumatology and Biosimilars Specialist Pharmacist, Deputy Chair, Rheumatology Pharmacists UK (RPUK).