Role of the pharmacist
of patients with PsA, and indeed other rheumatological conditions. As an example, there are increasing numbers of pharmacists undertaking clinical roles in rheumatology, frequently in outpatient clinics as part of a multidisciplinary team consisting of rheumatologists, specialists nurses, and other healthcare
professionals such as physiotherapists or occupational therapists. The involvement of pharmacists in these clinics has been greatly facilitated by the advent of pharmacist prescribing.
In the outpatient clinic setting, these specialist pharmacists may: ● Counsel patients on the use of new medications
● Monitor response to treatment, including clinical response using outcome measures such as PASI, and tolerance including reviewing the results of monitoring blood tests
● Identify and resolve any problems that may be impacting on patient adherence; for example, switching patients from oral to subcutaneous methotrexate if patients are experiencing nausea
● Adjust doses of medication in accordance with recognised protocols, for example, dose escalation of methotrexate
● Screen patients prior to the commencement of biologic therapies. Specialist pharmacists can also contribute indirectly to improving adherence and compliance with therapy. The Royal Pharmaceutical Society expects pharmacists to take the lead in ensuring that medicines optimisation becomes embedded into the daily practice of all front-line healthcare professionals; rheumatology pharmacists should rise to this challenge and champion MO within their teams, training and supporting other staff to apply the principles of MO in their daily clinical practice. Additionally, specialist pharmacists can provide training to other pharmacists within the same organisation and the wider health economy to ensure all are aware of the local nuances of
rheumatology practice; using case studies or vignettes in training sessions can help non-specialists to understand the patient’s experience of taking medicines for PsA, helping them to engage with patients and support shared decision making. This can also ensure that patients receive consistent messages about their medicines, so that the patient feels able to discuss their medicines with anyone
involved in their care. If this results in patients discussing potential side effects, then incidents of medicine-related avoidable harm can be reduced, in turn reducing medicines-related admissions and re-admissions to hospital. Finally, pharmacists can also ensure that the choice of medicines is evidence- based (Principle 2 of Medicines Optimisation) by monitoring clinician adherence to National Institute for Health and Care Excellence (NICE) guidance and local pathways, and helping to develop systems to record and measure patient outcomes. For example, several anti-
2. de Achaval S, Suarez-Almazor ME. Treatment adherence to disease-modifying antirheumatic drugs in patients with rheumatoid arthritis and systemic lupus erythematosus. Int J Clin Rheumatol 2010;5(3):313–26.
3. De Vera MA, Galo J. What are the effects of interventions targeting medication adherence in rheumatic diseases: A systematic review. Ann Rheum Dis 2014;73:Suppl 2 459 doi:10.1136/ annrheumdis-2014-eular.4753.
4. Bluett J et al. Impact of inadequate adherence on response to subcutaneously administered anti-tumour necrosis factor drugs: results from the Biologics in Rheumatoid Arthritis Genetics and Genomics Study Syndicate cohort. Rheumatology
“Increasing numbers of pharmacists are undertaking clinical roles in rheumatology, frequently as part of a multi-disciplinary team”
TNFs have positive NICE guidance for the treatment of PsA,9,10
with NICE making
the overall recommendation of choosing the treatment with the lowest acquisition cost in the furst year of treatment. Certolizumab pegol is licenced for PsA but is not currently on the NICE work programme, so local decisions can be made on the use of this agent for PsA; it has similar efficacy to other anti-TNFs but due to a Patient Access Scheme, it has the lowest acquisition cost in year 1.11 There are also several potential new treatments currently awaiting licensing (for example, apremilast, an oral phosphodiesterase-4 inhibitor, and secukinumab, an interleukin (IL)-17A inhibitor)12
or NICE approval
(ustekinumab, an IL-12/23 inhibitor),13 which will broaden treatment options for patients with PsA. However, the most effective sequence for using these new options is yet to be determined and pharmacists will need to be involved in developing medicines pathways to support the use of these new medicines.
Conclusions To conclude, although PsA is an uncommon condition that non-specialist pharmacists might not be aware of, all pharmacists can potentially improve the outcomes for their patients with this disease by applying the principles of MO to the specific needs of this patient group. ●
References 1. Coates LC et al. The 2012 BSR and BHPR guidelines for the treatment of psoriatic arthritis with biologics. Rheumatology 2013;52(10):1754–7.
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esnm42 (accessed 22 October 2014).
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