Role of the pharmacist
provide more therapeutic options for patients who may not have responded to other treatments. Pharmacists are well-placed to educate patients on the use of these new treatments; the setting for this could be quite variable. Specialist pharmacists working in rheumatology clinics can provide in-depth education to patients on the potential risks and benefits of the available treatment options, and counsel patients on the correct use of the medication at the same time. This would enable patients to make an informed decision about starting or changing treatments. A 2009 study found that whereas 61.5% of patients with PsA expressed a wish to actively participate in medical decision-making, only 9% were actively doing so.8
specialist pharmacists (whether working in secondary or primary care) will need to have a good understanding of these newer agents, as they are likely to encounter patients taking them as part of their practice and may need to offer advice on the use of these treatments to patients and their carers or medical team.
Patients with PsA are predisposed to developing a number of other conditions, including cardiovascular disease, type 2 diabetes and obesity. Hypertension is particularly problematic and was found to be present in 37% of PsA patients, versus 20% in patients with psoriasis alone. Additionally, more patients with PsA have neurological conditions, hepatic impairment and gastrointestinal disease compared with those with psoriasis.10
an attempt to overcome this, Rollefstad et al describe a preventative cardiac/ rheumatology clinic based on the unmet need of adequate cardiovascular protection in patients with inflammatory joint disease; two-thirds of the 426 patients reviewed required intervention to reduce lipid levels, with 82.9% of psoriatic arthritis patients achieving lipid targets compared with 90% of patients overall.11
However compliance with
medicines such as statins and antihypertensives has been long recognised as poor; however, pharmacist counselling and support for these patients has been shown to improve compliance,12 and this currently forms the basis of the New Medicines Service.13
Additionally, supporting patients with PsA to maintain healthy lifestyles is likely to reduce or prevent the development of some of these comorbidities, and
pharmacy could play a key role in this. The current NHS community pharmacy contract requires pharmacists to participate in health promotion campaigns and to offer interventions to promote healthy lifestyles linked to prescriptions.14
The Healthy Living
Pharmacy (HLP) concept (now being implemented across England) provides a commissioning framework for the development of public health services in community pharmacies. Evaluation of the pathfinder project found that these services were well received by the public and included smoking cessation (with a 67% success rate), brief advice on safe alcohol consumption using the Audit C tool, and support for weight loss.15 Although specialist and non-specialist hospital pharmacists may not be able to deliver these sorts of interventions (which require regular contact with the patient), they can identify patients who could benefit from these services, educate them on their increased risk of hypertension, hepatic impairment, etc, and refer appropriately. This may involve setting up referral pathways and providing additional training for staff working in HLPs, as the staff may not be aware of the association between psoriatic arthritis and the various comorbidities. This would assist pharmacists and their staff to personalise the advice they offer to their patients.
It is clear that patients with PsA have a number of unmet needs, and not only due to a current lack of treatment options when compared with rheumatoid arthritis. However, there are opportunities for pharmacists working in both primary and secondary care to become involved in the care of these patients; appropriate specialist pharmacists may contribute directly to the specialist care of these patients by providing medicines counselling in clinics, monitoring response to treatment and adjusting treatment. Non-specialist hospital pharmacists may be able to provide advice to these patients when they encounter them on during their routine practice. Community pharmacies could help patients with PsA by recognising and referring potential cases at an early stage. They could then provide education and support to help these patients adhere to treatment and live healthier lifestyles, reducing their risk of developing comorbid conditions associated with PsA and improving outcomes. l
References 1. Helliwell P et al. Qualifying unmet needs and improving standards of care in psoriatic arthritis. Arthritis Care Res 2014; Jul 21 [Epub ahead of print].
2. Giacomelli R et al. Quality of life and unmet needs in patients with inflammatory arthropathies: results from the multicentre, observational RAPSODIA study. Rheumatology (Oxford) 2014; Oct 6 [Epub ahead of print].
3. Boehncke WH, Menter A. Burden of disease: psoriasis and psoriatic arthritis. Am J Clin Dermatol 2013;14(5):377–88.
4. National Institute for Health and Care Excellence. Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis (TA199). www.nice.org.uk/guidance/TA199
(accessed 22 October 2014).
5. National Institute for Health and Care Excellence. Golimumab for the treatment of psoriatic arthritis (TA220). www.nice.org.uk/guidance/TA220
(accessed 22 October 2014).
6. National Institute for Health and Care Excellence. Ustekinumab for treating active psoriatic arthritis (TA313). www.nice.org.uk/guidance/TA313
(accessed 22 October 2014).
7. Lebwohl MG et al. Patient perspectives in the management of psoriasis: results from the population-based Multinational Assessment of Psoriasis and Psoriatic Arthritis Survey. J Am Acad Dermatol 2014;70(5):871–81 e1–30.
8. Leung YY et al. Involvement, satisfaction and unmet health care needs in patients with psoriatic arthritis. Rheumatology (Oxford) 2009;48(1):53–6.
9. Khalid JM et al. Treatment and referral patterns for psoriasis in United Kingdom primary care: a retrospective cohort study. BMC Dermatology 2013;13:9.
10. Husted JA et al. Cardiovascular and other comorbidities in patients with psoriatic arthritis: a comparison with patients with psoriasis. Arthritis Care Res 2011;63(12):1729–35.
11. Rollefstad S et al. Treatment to lipid targets in patients with inflammatory joint diseases in a preventive cardio-rheuma clinic. Ann Rheum Dis 2013;72(12):1968–74.
12. Elliott RA et al. The cost effectiveness of a telephone-based pharmacy advisory service to improve adherence to newly prescribed medicines. Pharm World Sci 2008;30(1):17–23.
13. Pharmaceutical Services Negotiating Committee. New Medicines Service – list of medicines. http:// psnc.org.uk/wp-content/uploads/2013/07/
NMS-medicines-list-Apr-2014.pdf (accessed 22 October 2014).
14. Pharmaceutical Services Negotiating Committee. Public Health – Promotion of Healthy Lifestyles. http://psnc.org.uk/services-commissioning/
essential-services/public-health/ (accessed 22 October 2014).
15. Duggan C et al. Evaluation of the Healthy Living Pharmacy Pathfinder Work Programme 2011 – 2012: Pharmaceutical Services Negotiating Committee; 2013.
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