Background Shared care guidelines are used by hospitals and primary care for drug toxicity monitoring in the UK. BSR has published guidelines stressing the importance of monitoring for early detection of toxicity. There is a wide variability amongst hospitals within a region on shared care arrangements. With considerable increase in DMARD prescriptions following early diagnosis and aggressive treatment, monitoring in hospitals have increased the workload. Primary care has efficient systems for various screening/immunisation programmes. Question arises if the initial drug toxicity monitoring could be managed by the primary care? So,we set to audit our DMARDs monitoring clinics to see if patients initiated on DMARDs have a higher incidence of drug related side effects in the first 3 months of treatment. This would indeed help relocating the specialist nursing resources to appropriate services.
Objectives To examine the incidence of DMARD related side effects in the first 3 months of treatment and feasibility of early referral to primary care for monitoring.
Methods An audit was carried out to identify the incidence of adverse effects in the first 3 months related to initiation of disease modifying drugs in patients with Rheumatological illnesses attending a district general hospital in the North west of UK over a period between July and November 2011. Patients, case notes and laboratory data were analysed for drug related side effects; course of action in the event of a side effect and interventions if any,were audited. Patients on escalating doses of DMARDS were studied for 3 months. Patients who could not be treated for 3 months were excluded. Blood counts, biochemistry and systemic features were also looked into.
Results The number of patients audited in the period were 50. The female to male ratio was 1.5. Underlying rheumatological conditions were RA (n=38), Psoriatic arthritis (n=6), Ankylosing spondylitis (n=2) and other CTDs (n=4). Drugs used included Methotrexate (n=30), Leflunomide (n=6), Sulfasalazine (n=5), Azathioprine (n=3), MMF (N=2) and combination therapy (n=4). The commonest side effect was deranged LFTs (n=5), neutropenia (n=2), Rash (n=2) and diarrhoea (n=2). The drugs were stopped in 9(18%) cases and were either switched to an alternate drug or restarted in 7(78%) cases. None of the patients needed other specialty interventions or admissions due to complications.
Conclusions The incidence of side effects associated with DMARDs use was relatively low in the first three months of hospital monitoring in the cohort audited.
Recommendations: Given the low incidence and the relatively mild characteristics of side effects reported, we think that monitoring of DMARDs toxicity could safely and appropriately be shifted to the primary care setting. Input from hospital rheumatology team is an essential complement to the shared monitoring protocol and should be based on open access and regular liaison.We believe this would help to redirect rheumatology specialist nurses effort to provide disease activity monitoring and convey advice on urgent management plans.We also hope that the primary care nurses would acquire new skills that would extend their role in monitoring DMARDs.
Chakravarty K, McDonald H, Pullar T, et al. BSR/BHPR guideline for disease-modifying anti-rheumaticdrug (DMARD) therapy in consultation with the British Association of Dermatologists. Rheumatology 2008; 47:924-5.
Disclosure of Interest None Declared
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