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Role of the pharmacist


majority of referrals made at initial presentation to the GP.3


However, recent


evidence suggests that 25–45% of psoriasis patients have moderate to severe disease and would benefit from specialist attention, particularly as more potent, more specific systemic therapies, including phototherapy and biologics, are usually only used on specialist advice. Additionally, although most patients treated with an anti-TNF will achieve a 75% improvement in their Psoriasis Area and Severity Index (PASI) within a reasonable timeframe, only 20–57% of patients reach a 90% improvement in this measure.


A systematic review found that adherence to prescribed treatments for psoriasis is often suboptimal, with 21–66% of patients classed as adherent in the included studies. Psychological factors (psychological distress and patient satisfaction with care and therapy) were associated with greater adherence.4 Pharmacists are well placed to understand the experience of patients with these therapies. In the UK, many patients are likely to be treated with topical treatments in primary care but might have moderate to severe disease and could benefit from more specialised care. Community and hospital


providers; the result is that community pharmacists are unlikely to dispense them and may not be aware that their patients are using them. A similar situation may prevail in hospitals; in the UK, dermatology is a predominantly outpatient specialty and therefore non-specialist hospital pharmacists have limited opportunities to become involved in the care of psoriasis patients on these therapies. As a result, their knowledge on available treatment modalities may not always be entirely up-to-date, but as there can be significant interactions or side effects to these treatments, pharmacists need to be aware of them so that they can advise their patients appropriately. Specialist pharmacists can have varying roles in the care of these patients. Pharmacist-led clinics are becoming more common in primary and secondary care and pharmacists working in these clinics might be involved in screening patients for biologic treatments, advising on the choice of therapy, monitoring response to treatment and, where applicable, adjusting doses according to various parameters.


Evidence-based choice of medicines Because biologic therapies are generally nominally more expensive than other


“Pharmacists might be involved in screening patients for biologic therapies, advising on choice of therapy and monitoring response to treatment”


pharmacists can ask patients with psoriasis about their satisfaction with treatment and signpost patients with persistent disease back to their GP for onward referral. This could take place during medication reviews with the patient, or opportunistically when patients collect dispensed prescriptions from the pharmacy. Providing pharmacists, particularly those in community pharmacy, with good quality information materials from accredited sources can help to reinforce these messages, and if the leaflets are freely available for patients to browse while in the pharmacy, this may also prompt them to seek advice from the pharmacist. It is also important for pharmacists to maintain their knowledge of new and specialist treatments for psoriasis. In the UK, many of the specialist-initiated systemic therapies for psoriasis are only available through hospitals or homecare


treatments, it is important to ensure that their use is evidence-based and the product of rational decisional making. Guidelines relating to the use of biologics in psoriasis and other conditions have been developed by various organisations; including professional societies such as the British Association of Dermatologists, or government organisations such as the National Institute for Health and Care Excellence (NICE) in England. Adherence to these guidelines may be mandatory – for example, in England any treatment approved by NICE must be made available to the relevant patient group within 90 days of the publication of the guidance; use outside of these guidelines may not be funded by commissioners or insurers unless prior approval is sought. As an example, NICE currently recommend biologics for patients with severe psoriasis who have previously failed treatment with standard systemic


therapies including methotrexate, ciclosporin and PUVA (psoralen and long-wave ultraviolet radiation). There are slight differences in the recommendations for each biologic; etanercept (an anti-TNF treatment), ustekinumab (an anti-IL12/23 mAb) and adalimumab (an anti-TNF mAb) can be used in patients with a PASI ≥10 and a Dermatology Life Quality Index (DLQI) of >10.5–7


However, infliximab (an anti-TNF mAb) is only recommended for patients with a PASI ≥20 and a DLQI >18.8


A


and an appraisal for apremilast (a small-molecule PDE4 inhibitor), is expected in August 2015.10 However, in the case of single technology appraisals, NICE only recommends whether certain treatments should be funded or not by the British National Health Service. Clinicians can then freely decide which of the recommended treatments they will use for their patients. Over the past few years, there has been an increase in the number of manufacturers offering Patient Access Schemes (PAS) and other programmes to reduce the cost of their drugs in certain circumstances; these programmes may improve the cost-effectiveness of the treatment when analysed by NICE or similar bodies, or may be used commercially to give their product a competitive edge over other similarly- priced treatments. For example, the NICE appraisal for ustekinumab requires the manufacturer to make the 90mg dose available for the same price as the 45mg dose.7


technology appraisal for secukinumab (an anti-IL-17A mAb) was published in July 20159


Furthermore, early 2015 saw the Europe-wide launch of the first biosimilar infliximab following the expiry of the patent on the originator product. A biosimilar is a new biological product that has been developed to be similar to an existing biological product (‘reference’ product), in this case, infliximab. Biological products are fundamentally different from standard chemical products in terms of their complexity, and it is unlikely that the biosimilar product will have an identical structure to that of the reference product, thereby requiring evidence of safety and efficacy before approval. In this regard, biosimilars are different to the more familiar generic products.11


Like generics, biosimilars are available at reduced cost, with current infliximab biosimilars being approximately 40% cheaper than the


www.hospitalpharmacyeurope.com 27


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