Introduction Increasing numbers of patients are being treated with immunomodulators (IMD) for inflammatory bowel disease (IBD) and autoimmune hepatitis (AIH). This needs intensive monitoring and impacts by increasing clinic waiting times. After approval from the Quality and Safety Board of the Trust, a pharmacist led IMD clinic was established in 2012 to manage patients initiated on IMD for initial monitoring and dose titration with a view to reduced clinic visits.
Methods Patients were referred to the pharmacist led clinic by the gastroenterologists and IBD nurse specialist for commencing and monitoring of IMD after initial counselling. Screening blood tests including the TPMT assay were checked prior to commencing the IMD as per agreed protocol. The pharmacist issued prescriptions and patients were given blood forms for weekly tests for the initial two months, fortnightly for the next two months and three monthly thereafter. Results were monitored by the pharmacist and patients were offered a choice of telephone or email consultations with the pharmacist for subsequent appointments. The pharmacist had easy access to advice from the clinician in the event of adverse effects. After initial stabilisation patients were referred back to the GP or the referring clinician for follow up.
Results 81 patients were referred to the pharmacist led IMD clinic between October 2012–2013 [(50F); Median age 44 (range 19–76)]. Indications for treatment were IBD (n = 73) [ulcerative colitis (n = 33), Crohn’s (n = 40)] and AIH (n = 8). Twenty seven patients (33.3%) experienced side effects between weeks 2 to 6 of initiation of treatment. These were nausea or vomiting 16% (n = 13), skin rash 1% (n = 1), fatigue 1% (n = 1),myalgia 1% (n = 1), intolerance 1% (n = 1) and stomach cramps 1% (n = 1). Abnormal blood tests were noted in 23.4% (n = 19) patients. These were abnormal liver tests [predominantly transaminitis] (n = 11); myelosupression (n = 6). Six patients were admitted to hospital [myelosuppression n = 2, pancreatitis n = 1, unrelated to IMD n = 3]. Management of adverse events included changing to an alternative agent (n = 13), dose adjustment (n = 12) and discontinuation of IMD (n = 10).
Conclusion A pharmacist-led clinic is a safe alternative to conventional gastroenterology clinics for monitoring of patients on IMD. Adverse events were picked up early and adequately acted upon. There was a high level of patient compliance and reduced number of clinic visits; the average numbers of clinic visits saved were 10 per patient.
References Jenkins J, British Journal of Clinical Pharmacy. 1:219–220
Das J, Hospital Pharmacist. January 2008
Disclosure of Interest None Declared.
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