Thursday
Thursday is clinic day. This is the day I put my pharmacist practitioner hat on. I work in the early arthritis clinic alongside a consultant, registrar, extended scope physiotherapist, GP trainee, nurse specialist and a team of HCAs. This is a truly collaborative approach, bringing together the skills and expertise of each profession to offer the patient a holistic service. As a pharmacist practitioner, I review patients with a diagnosis of early arthritis and ensure their disease is being controlled on current drug treatment. When assessing, I look at the patient’s current health, the level of inflammation in their blood (ESR/CRP) and how they are coping with treatment. I review compliance and concordance and ensure that the medicines prescribed for them are optimised fully.
I physically assess patients by feeling for hot, red, swollen joints and synovitis. Synovitis and swollen joints suggest poor disease control and active disease. When I first began assessing joints, I struggled with physical assessments but was reassured when told it takes years to master – even by doctors. In the clinic, as a measure of quality control, we always peer review joint counts to ensure our assessment skills are adequate. After counting the number of swollen joints, we calculate a disease activity score (DAS) score to guide us in treatment.
Today, I see an interesting patient in clinic who has rheumatoid arthritis. He had been taking methotrexate and hydroxychloroquine for eight months now at the maximum tolerable dose (including sc mtx). On assessment, he has 15 swollen joints, producing a DAS score of 7.65 (any score above 5.1 is severe and qualifies for biologics treatment). I consider his options and inform him that his treatment needs escalation to a biologic. He understands and agrees he needs more help. The patient was born outside the UK so I refer him to infectious diseases for the screening of tuberculosis to ensure he is clear to start treatment. I also explain to the patient we have to run a series of baseline tests to ensure he is safe to take biologics – this includes screening him for HIV, Hepatitis B/C and a chest x-ray. He consents. I run the plan by my consultant who comes and assesses the patient and agrees he needs stronger treatment. I refer the patient as above and give him an information pack. I complete the patient’s written medical notes and dictate a letter using our dictator phone programme. I then see four other patients and perform similar tasks, referring one patient to physiotherapy and another to podiatry. One patient requires amitriptyline to help with nerve pains before bedtime. She also takes levetiracetam as she is epileptic. I, therefore, advise her on the potential for the amitriptyline to lower her seizure threshold and report back any increased frequency of seizures. I prescribe the drug with caution, having weighed up the pros and cons, documenting my rationale and advice to the patient too.
Thursdays are busy days indeed, clinics take up the whole morning and by the time I get back to my desk, it is sometimes 2 pm. I then check any emails from the morning, any queries or outstanding results. I go back to the Arthritis centre at around 3 pm to touch base with the specialist nurses and see if they need help with any medicines-related issues. I work very closely with the nurses, providing support and expertise on medicines which they thoroughly appreciate.
I then start planning on a new project I am working on involving biosimilars and how I can continue to save money by adopting up and coming biosimilars into our practice. Project management is a large part of my role and I enjoy this element of the job too.
Should pharmacists be able to physically assess patients?
Kalveer Flora is Lead Rheumatology and Biosimilars Specialist Pharmacist, Deputy Chair, Rheumatology Pharmacists UK (RPUK).
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Kalveer Flora