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Physician–pharmacist collaborative care improves nb-DMARD dose optimization, adherence

Stephen Padilla
10 Sep 2019

Implementation of the collaborative care in a rheumatoid arthritis (RA) clinic has led to improvements in nonbiologic disease-modifying antirheumatic drugs (nb-DMARDs) optimization, adherence to safety recommendations on nb-DMARD monitoring and detection of adverse drug events in RA patients, according to a Singapore study.

“Collaborative RA care contributed to improvements in nb-DMARD dose optimization, compliance to hospital guidelines on monitoring and the detection of nb-DMARD-related adverse drug events,” the researchers said.

A total of 38 patients who had received standard care and collaborative care were included in the analysis. More patients in the collaborative vs standard care group achieved nb-DMARD dose optimization within a year of therapy initiation (68.4 percent vs 39.5 percent; p<0.05) and complied with safety recommendations from hospital guidelines on nb-DMARD monitoring (70.6 percent vs 44.1 percent; p<0.05). [Proceedings of Singapore Healthcare 2019;28:184-192]

Collaborative care also contributed to increased detection of the incidence of nb-DMARD-associated adverse drug events (26.3 percent vs 18.4 percent; p<0.05), the most common of which were gastrointestinal (29.4 percent), dermatological (17.6 percent) and haematologic (17.6 percent). Majority of these events were mild in severity.

Most adverse effects occur within the first 3 months of nb-DMARD treatment, according to a previous report, which is why the American College of Rheumatology recommends full blood counts, liver transaminase levels and serum creatinine levels to be monitored every 2–4 weeks during the induction phase. [Arthritis Rheumatol 2002;47:181-188]

“The study demonstrated that a greater proportion of patients under the collaborative care model achieved optimal dose of DMARD at 6 months, 9 months, and 1 year from initiation,” the researchers said. “Early treatment and rapid dose escalation to optimize nb-DMARD treatment has been shown to be beneficial in achieving disease remission.” [Clin Exp Rheum 2003;21(5 Suppl 31):S154-S157]

The collaborative care model allowed pharmacists to supplement physician consultations (about two follow-up visits within a year) without any deleterious effect on patient care. Pharmacist involvement also did not statistically increase healthcare utilization costs.

“The collaborative care model optimized manpower resources and contributed to a sustainable healthcare system, as well as leading to better and more prompt detection of any adverse effects of nb-DMARDs on patients,” the researchers said.

A retrospective review of patient case notes and medication records was conducted from March 2013 to February 2016 to examine the effectiveness and safety of collaborative care in preimplementation (standard care) vs postimplementation (collaborative care) cohorts. Patients were evaluated for 12 months.

The percentage of patients achieving optimal doses of nb-DMARDs was used to measure clinical effectiveness. Clinic safety performance was assessed using the percentage of patients in each cohort that achieved compliance to in-house hospital guidelines on nb-DMARD monitoring. Other clinic safety factors monitored were incidence and characteristics of nb-DMARD-related adverse drug events.

This study was limited by its small sample size and its retrospective collection of some data from the case notes. In addition, data on the number of swollen or tender joints, or patient’s global assessments of health, were not collected as these were not available.

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