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Introduced a system to monitor DMARDs

Dr Asif Malik describes a system to monitor patients on disease modifying anti-rheumatic drugs that qualified as a national enhanced service

Dr Asif Malik describes a system to monitor patients on disease modifying anti-rheumatic drugs that qualified as a national enhanced service


Disease-modifying antirheumatic drugs (DMARDs) have been shown to be effective against many diseases and are being used in many areas of medicine, especially rheumatology, gastroenterology and dermatology. Evidence has shown that because of adverse drug reactions, significant numbers of patients on DMARDs discontinue therapy1. There has been an increasing push for shared care in DMARD monitoring, and if GPs are to be part of a successful shared-care arrangement, a simple but effective monitoring system is needed.

Our large practice in a deprived area of inner-city Birmingham has six partners for a list size of more than 10,500. Our population mix harbours a lot of co-morbidities, and has a significant elderly population so we have a high proportion of patients on DMARDs.During a triage session I came across a request from a patient for re-authorisation of her azathioprine, which I noticed was on a repeat for six months. Looking through her notes it was evident she had had no blood monitoring for six months and clearly our system to monitor DMARDs was not working properly.By chance this happened soon after, as a relatively new partner to the practice, I had had a meeting with the PCT pharmacy adviser. I had taken on medicines management as one of my QOF areas, and we decided to identify three potential areas of improvement in medicines management (MED 6).

What we did

It was important to find out how different hospitals in the region monitored their patients on DMARDs. I contacted specialist nurses in rheumatology and gastroenterology, and the dermatologists from the hospitals who kindly forwarded their monitoring details. It soon became apparent that the hospitals had adapted the monitoring frequencies to their own working habits as each guidance differed from the next.

Using the British Society for Rheumatology's National Guidelines for the Monitoring of Second Line Drugs2 as a template, and with the guidelines from the respective hospitals, our practice guidelines were created. They were sent to all the relevant consultants and departments looking after our patients in secondary care to ensure they were in agreement.A search was carried out on our Vision system to identify all patients on repeats of DMARDs. We initially found 56 patients of whom 34 were not being monitored according to our guidelines. A register was then created and patients were divided using the appropriate Read codes into those monitored at the practice (66P7 – high-risk drug monitoring primary care), and those in secondary care (66P9 – high-risk drug monitoring secondary care). A template was constructed for ease of use and, as well as including the above two Read codes, also displayed 'add recall' (7L172 – blood withdrawal for testing), for setting the recall date. Additional entries on the template include symptom/medication side-effect inquiries, a reminder to give a drug information leaflet3 if needed, discussion about therapy, and the care plan agreed, which would include discussions on the reason for treatment and its proposed duration. Every two weeks a search is run for patients with the primary care monitoring Read code who also have the blood withdrawal for testing Read code ( recall date) retrospectively for the last five weeks. This effectively allows the team to identify patients who have not attended at their recall date, because this is reset by the nursing team when the patients are seen. Reminder letters can then be generated. The five-week retrospective search allows non-attenders to be identified twice, prompting further appropriate action. Also the number of repeats allowed for each drug is altered appropriately depending on monitoring intervals. This service fulfilled the criteria for the national enhanced service for the provision of near-patient testing so we are also able to receive NES payments for carrying it out.

What we have achieved

An audit run six months after full initiation of the monitoring service revealed a total of 71 patients on the register and 70 were being monitored according to our guidelines. The other patient was being monitored in secondary care. The system clearly is working well and its set-up has involved multi-disciplinary efforts, which has boosted teamwork.

The initial set-up required a little time and research, and nurse appointments for such patients are longer than those for standard blood withdrawals, but the near-patient testing payments have allowed us to run the service effectively without compromising appointment availability.

With the benefit of hindsight

As a practice we feel we have created a safe, efficient and effective monitoring service, to the satisfaction of our patients, which allows safe prescribing of DMARDs.

It is imperative when setting up the system to work with secondary care as this is a shared-care arrangement. Given that the nursing team are going to be undertaking the monitoring it is important they are comfortable with the protocol, and the template/protocol is simple but achieves its aims.Importantly, for the monitoring system to work well, old recalls need to be deleted so the search picks up the correct patients. Having a reminder statement by the 'add recall' tab is useful. After DMARD monitoring blood results are generated, so it is useful for each patient to have a designated GP to spread out the results workload equitably among partners.

Dr Asif Malik is a GP principal at Eaton Wood Medical Centre, Erdington, Birmingham

Competing interests None declared

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