Role of the pharmacist
reference product. Further biosimilar launches are expected in the coming years, offering similar savings, with biosimilar etanercept and adalimumab currently in development. However, biosimilars are not currently considered interchangeable with the reference product, or with each other, owing to lack of data.
The increasingly complex market for biologics resulting from the introduction of PAS, commercial programmes and biosimilars almost certainly makes it worthwhile developing local guidelines that take into account these factors, and recommend the appropriate use of each biologic. While it is difficult to develop a guideline that will be applicable to all patients, it is probably not unreasonable to aim for 90–95% compliance, which allows clinicians the flexibility to tailor treatment to individual patient factors. Pharmacists should be involved at an early stage in developing these guidelines, and can participate in evaluating the evidence base and undertaking modelling to inform decisions around which biologic to use first-line, second-line, etc. This may involve developing an algorithm that suggests certain biologics for certain patient groups; for example, biosimilar infliximab, an anti-TNF mAb, is likely to be the least expensive option for patients with low body mass because dosing is weight-based, even allowing for the cost of admission to administer the drug. However, it might not be possible for patients to attend on an eight-weekly basis for infliximab infusions, so alternative treatments might need to be offered. Conversely, some patients who are needle-phobic may be unable to self-inject, in which case, attending hospital to have an infusion administered less often than injections may be a preferred option. Finally, pharmacists can contribute to multi-disciplinary team meetings and be involved in treatment decisions for individual patients.
Ensure medicines use is as safe as possible
As immunomodulatory agents, some of the risks of biologic therapy may include increased risk of infections and possibly of malignancy. Pharmacists have a number of roles to play in mitigating these risks, and ensuring the safe use of medicines is one of their major responsibilities.
Patient education and counselling provides an opportunity for pharmacists
to inform patients about the potential risks and benefits of their proposed treatment, enabling the patient to make an informed decision. Patients can also be given advice on the importance of promptly recognising and taking action if they develop unwanted effects – for example, to suspend treatment if they have an infection. Again, this could be a role for specialist pharmacists in clinics, but more generalist pharmacists should also be aware of the potential problems associated with these therapies as they may need to advise patients, carers or other healthcare professionals on effective management. The Summary of Product
Characteristics (SPC) for all biologics specify various investigations that should be considered prior to initiating therapy; for example, the SPC for secukinumab states that, “anti-tuberculosis therapy should be considered prior to initiation of [secukinumab] in patients with latent tuberculosis (TB)”,12
so, it is being
recommended to screen patients for latent TB if, for example, the physician is not able with reasonable confidence to exclude latent TB in a patient (for example, due to recent testing). Pharmacists who are clinically checking prescriptions for biologics should (where appropriate) ensure these investigations have been completed. Additionally, specialist pharmacists may become involved in developing screening protocols for use in their centres to ensure the process is completed correctly.
Making MO part of routine practice Using the MO framework, it is clear that both specialist and generalist pharmacists in a variety of care settings can play a part in the management of patients with psoriasis; many patients with psoriasis can benefit from specialist input, and community pharmacists may be able to identify some of these patients and refer them to their GP for further assessment. Specialist pharmacists working as part of a multi-disciplinary dermatology team can contribute to guideline development, helping to ensure the evidence-based and safe use of medicines. They may also have a more hands-on clinical role, working in clinics alongside other healthcare professionals to counsel and monitor patients on these therapies. Non- specialist pharmacists need to be aware of biologic therapies so they can advise patients appropriately, for example, if a patient presents in a community
pharmacy seeking advice to treat an infection.
In conclusion, pharmacists are well placed to understand the experience of patients with psoriasis and should be able to use their expert knowledge to promote the effective and optimal treatment of this condition. ●
References 1. Royal Pharmaceutical Society of Great Britain. Medicines optimisation: Helping patients to make the most of medicines. Good practice guidance for healthcare professionals in England. London: RPSGB;2014.
2. 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.
3. Khalid JM et al. Treatment and referral patterns for psoriasis in United Kingdom primary care: a retrospective cohort study. BMC Dermatol 2013;13:9.
4. Thorneloe RJ et al. Adherence to medication in patients with psoriasis: a systematic literature review. Br J Dermatol 2013;168(1):20–31.
5. National Institute for Health and Care Excellence. Etanercept and efalizumab for the treatment of adults with psoriasis (TA103). www.nice.org.uk/
guidance/ta103 (accessed 15 June 2015).
6. National Institute for Health and Care Excellence. Adalimumab for the treatment of adults with psoriasis (TA146). www.nice.org.uk/guidance/
ta146 (accessed 28 September 2015).
7. National Institute for Health and Care Excellence. Ustekinumab for the treatment of adults with psoriasis (TA180). www.nice.org.uk/guidance/
ta180 (accessed 28 September 2015).
8. National Institute for Health and Care Excellence. Infliximab for the treatment of adults with psoriasis (TA134). www.nice.org.uk/guidance/
ta134 (accessed 28 September 2015).
9. National Institute for Health and Care Excellence. Secukinumab for treating moderate to severe plaque psoriasis. www.nice.org.uk/guidance/
ta350 (accessed 28 September 2015).
10. National Institute for Health and Care Excellence. Psoriasis (plaque, moderate to severe) – apremilast [ID679]. www.nice.org.uk/guidance/
indevelopment/gid-tag469 (accessed 28 September 2015).
11. Medicines and Healthcare Products Regulatory Agency. Drug safety update. Biosimilar products. www.gov.uk/drug-safety-update/biosimilar-
products (accessed 28 September 2015)
12. Cosentyx 150mg solution for injection. Summary of Product Characteristics. Novartis Pharmaceuticals UK Ltd. www.medicines.org.uk/emc/
medicine/29848 (accessed 28 September 2015).
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