Wednesday mornings are subcutaneous methotrexate (sc mtx). Currently, all prescriptions for sc mtx are screened by myself to ensure safety and that patient bloods are in order. We have around 200 patients injecting sc mtx due to oral intolerance or short bowel. Methotrexate is a safe and effective drug when used for its immunosuppressive properties in inflammatory conditions. All stable patients must have three monthly bloods and are taught how to self inject. Methotrexate is one of our first line treatments in rheumatology and therefore its use must be optimised before we consider escalation to another treatment. Using sc mtx over oral when patients cannot tolerate the oral route is one way of making the most of treatment.
Just like any other clinical intervention, if there is a deranged blood result, I use my professional judgement to make a plan. For example, today, Mr X has had an ALT result of 99 – this is higher than his usual baseline of 50. He, therefore, needs to withhold his next dose of mtx and repeat his blood test. If his ALT is still raised the dose may be too high and need reducing. I also need to think of other reasons his ALT may be raised? Alcohol? Drugs? fatty liver? Infection? These need to be eliminated accordingly. Once screened, the prescriptions are processed by the dispensary teams and issued to patients who collect them from the pharmacy.
After screening methotrexate, I have a pile of biologic scripts to screen. These on average vary between 20-30 prescriptions a week. Each prescription needs to be checked for safe bloods and that funding is secured for each patient. If patients are continuing therapy, there are fewer blood checks that need to be done opposed to those initiating therapy (see previous post). Once screened, I pass these over to my technician who processes the prescriptions and sends them off to our homecare provider to deliver the drugs to the patient.
Next, I have a catch-up with my junior pharmacist and her progress with her diploma. I check that she is on track to completing the relevant assessments needed for her portfolio and ensure she is performing at the required standard. We go through a few clinical interventions she has made, and I get her to reflect on her performance. Once again, I thoroughly enjoy the education and training aspect of my job.
Wednesday afternoons in rheumatology are dedicated to clinical teaching, clinical governance or service meetings. There are no clinics that run on Wednesday afternoons apart from an hour-long injection clinic. This allows for fully integrated MDT learning and time set out each week to promote education, training and growth of the team. Today is clinical governance, where we will discuss pathways, audits, NICE updates and any other business. Members from the two other hospital sites also attend so that we can move forward with collaborative working. I present, along with a consultant and registrar, the new rheumatoid arthritis biologics pathway we have been designing to the department, welcoming any feedback. Designing and agreeing on treatment pathways is hard work as opinions and clinical experience may sometimes not match. This coupled with the array of treatment options available, makes medicines optimisation a tough job. Never the less I relish the challenges.
We also learn about the new way in which to refer patients to infectious diseases from rheumatology. As we use quite potent immunosuppressive drugs in rheumatology, patients are susceptible to picking up opportunistic infections. London has a high risk of TB, therefore before commencing treatment, we screen all our patients for the presence of TB. Our infectious diseases team will review high-risk patients (those born outside the UK or with close contacts of TB) and then give us the all clear to go ahead with drug therapy e.g. biologics.
How important do you think inter-speciality working is?
Kalveer Flora is Lead Rheumatology and Biosimilars Specialist Pharmacist, Deputy Chair, Rheumatology Pharmacists UK (RPUK).