Background Methotrexate (MTX) is widely used as a disease modifying agent in rheumatic disease.1 The National Patient Safety Agency (UK) have previously highlighted the potential hazards of MTX therapy and requested that National Health Service (NHS) organisations ensure that MTX is monitored effectively and safely.2 The necessity for close monitoring with regular blood tests is twofold; to monitor for adverse effects and secondly to help evaluate response to treatment.
Objectives Our objective was to assess the impact that the introduction of a shared care scheme with General Practitioners (GPs) has had on MTX monitoring efficacy. Under this scheme, the GP is responsible for the all aspects of blood test monitoring for the patient while they are on MTX.
Methods Fifty patients were randomly selected from our internal database of patients on the shared care scheme. The British Society of Rheumatology (BSR) guideline for MTX monitoring was used as our standard.3,4,5 A retrospective analysis of all blood test monitoring over the preceding 6 months was undertaken. Results obtained were compared to 4 other data series' from rheumatology departmental blood test monitoring audits (2003, 2004 and 2007-2008).
Results See Table.
There is a clearly demonstrable and consecutive improvement in adherence to BSR guidance since 2003. An interesting subgroup analysis of our cohort demonstrates that 38% of patients had blood test monitoring at a frequency above the recommended minimal standards in 2013. This was substantially higher than previously observed in earlier data collections.
Conclusions There is marginally improved adherence to monitoring in the shared care scheme, versus the last cohort of patients who had departmental monitoring (2007-2008). This suggests that the new shared care scheme is certainly non-inferior and possibly slightly superior to departmental monitoring.
It may be postulated that the patients being over-monitored are having blood tests for separate purposes entirely or opportunistically when blood tests are indicated for an unrelated issue, or both.
Our data would suggest that the majority of patients established on DMARD therapy can have their blood tests monitored successfully by GPs under shared care schemes.
By encouraging and empowering GPs to participate in shared care monitoring schemes, NHS costs and resources could potentially be significantly reduced. Furthermore, the gap between primary and secondary care could be bridged, with patients ultimately benefiting from a more optimal level of drug monitoring and a more collaborative approach to care. Should such schemes be utilised more widely?
Methotrexate Drug Monograph. Martindale: The complete Drug Reference. The Pharmaceutical Press 2007. www.medscape.com
Improving Compliance with Oral Methotrexate Guidelines. National Patient Safety Agency (NPSA)/2006/13; 1 June 2006
British National Formulary (BNF) No 52 September 2006. Pharmaceutical Press
National Guidelines for the monitoring of second line agents. British Society of Rheumatology; p7; July 2000 accessed at www.rheumatology.org.uk
BSR/BHPR guideline for DMARD therapy in consultation with British Association of Dermatologists. Chakravarty et al. Rheumatology 2008
Acknowledgements Dr Mark Pugh (Consultant Rheumatologist, St. Mary's Hospital, Isle of Wight).
Disclosure of Interest None declared
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.