The royal pharmaceutical society (RPS) states that medicines optimisation is ‘a patient-focused approach to get the most out of the medicines they are prescribed. It requires a holistic approach, an enhanced level of patient centred professionalism and partnership between clinical professionals and the patient.’1 Mrs Gardner is an example of a patient that may benefit from the application of this approach. She is a regular customer at the community pharmacy and has brought a prescription for Trimethoprim 200mg twice a day for 7 days for a urine infection.
Mrs Gardner is a 70-year-old lady who had been diagnosed with rheumatoid arthritis (RA) 8 years ago. She currently lives alone at home as her husband passed away 4 years ago and has two sons who live far away. She does not smoke and rarely drinks alcohol. Her hobbies include meeting up with friends and going to the local bridge club at her community centre every Monday afternoon. However, for the last few weeks, she had not felt like going. This may be resultant of her RA not being controlled and she may be experiencing flare-ups or could be due to other reasons like depression. She does not have any known allergies. Her current monthly medication includes Methotrexate, Folic Acid, Sulfasalazine, Hydroxychloroquine, Ibuprofen, Omeprazole, Paracetamol and Humira (Adalimumab).
The RPS breaks the principles of medicines optimisation into four categories. Principle one aims to understand the patient’s experience.1 This is usually achieved by having a consultation with the patient or carer. A private consultation with Mrs Gardner about her medication will allow the pharmacists to discuss any concerns. It is also important that all patient medication record is obtained, including any over the counter and hospital medications.2 The pharmacists should also consider her social and holistic parameters by ensuring she is able to cope with everyday activities such as opening blister packs. This should be particularly concerning due to her condition, as well as her recent bereavement and living alone, all of which would have increased her workload. If Mrs Gardner is struggling to cope with daily activities then the pharmacists should refer her to a suitable personnel like her General Practitioner (GP) or a professional organisation such as the National Rheumatoid Arthritis Society.3 Pharmacists should encourage patients to not miss any monitoring checks and to be aware of their disease activity score 28.2 Furthermore, it might be useful for her to keep a diary for recording flare-ups. Signposting should be considered in this case as Mrs Gardner is exhibiting signs of depression which is frequent in adults with RA. Find out from Mrs Gardner how she is managing her medications. This is important as her husband may have managed her medicines before he passed away. Check if her RA is well controlled and if she had any flare-ups recently. If so, ensure her pain medication is sufficient. In the case of Mrs Gardner Ibuprofen may not be suitable as she is 70 and it is not recommended to prescribe NSAIDs with methotrexate.2 Emphasise the importance of adherence as patients do not always take their prescribed medications as intended by the prescriber.4 If she is struggling then alternative ways of obtaining compliance should be sought, such as alarms, timers and trays. In the case of RA, when patients experience remission they may falsely believe they do not require medication any more. This can cause further flare-ups and needs to be addressed with Mrs Gardner.
Pharmacists should advise patients with RA to adopt a ‘Mediterranean-style’ diet as it has been found to be beneficial.5 However, The National Institute for Health and Care Excellence (NICE) states that there is no strong evidence to support this but they could still be encouraged to follow the principles of a Mediterranean diet.4 The Scottish Intercollegiate Guidelines Network indicate that dietary supplements like fish oils may reduce RA symptoms but has no effect on disease activity or RA progression, but the National Rheumatoid Arthritis Society states otherwise about disease activity.63 On the other hand, NICE does not mention the use of supplements in RA. Mrs Gardner may also benefit from regular exercise and signposting to a physiotherapist may be beneficial as stated in NICE guidelines. The pharmacists should also check if she had a flu vaccination as she qualifies for a free one under the NHS.
Mrs Gardner has brought in a prescription for trimethoprim which has been prescribed for a urine infection. Ensure this antibiotic is the most suitable for this patient who is on regular medication of methotrexate.7 Find out how long the urine infection has occurred for and if this has been affecting her everyday activities like meeting up with her friends and playing bridge. Urinary tract infections (UTIs) can be recurrent and her regular medication for RA may need to be halted while she proceeds with the course of antibiotics. This is because Disease-Modifying Anti-Rheumatic Drugs are immune suppressing, therefore they need to be stopped while antibiotics are taken and restarted afterwards for better outcomes.7 She is currently living at home alone, find out if she is able to manage her medications. If not, signpost her as mentioned above. Make sure she fully understands how to take her medications and what to expect. The pharmacist should confirm if she is still getting the desired effects from her medications. Advise her on alcohol and staying under the recommended limit when she does drink due to increased risks of hepatotoxicity.
Principle two illustrates evidence-based choice of medicines. This means that medications prescribed must be the most appropriate choice, both clinically and cost-effectively, based on up to date evidence that meets the needs of the patient.1 Firstly, Mrs Gardner’s current medication needs reviewing. The concurrent use of sulfasalazine and methotrexate can increase the risk of hepatotoxicity and myelosuppression.8 This is particularly concerning in the case of Mrs Gardner as she is elderly, and her liver function can be affected drastically, especially since she is taking paracetamol for pain relief which also has a hepatotoxic effect when taken with sulfasalazine.8 Furthermore, decreased immune cells due to myelosuppression can cause UTIs to constantly reoccur. Similarly, folic acid absorption can be decreased but there is only a moderate study to support this.8 Therefore, the need for sulfasalazine needs to be evaluated as she is currently taking the maximum dose.8 Secondly, the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen is not recommended in elderly patients. This is due to a number of reasons such as developing renal impairment and a higher risk of acute renal failure.9 10 Additionally, there have been some studies which suggest the consumption of NSAIDs also increase the risk of congestive heart failure.11 Therefore, the suitability of NSAIDs in Mrs Gardner would need to be investigated. Similarly, in this case, Ibuprofen could potentially cause elevated toxicity risks with methotrexate as well as nephrotoxicity.8 Consequently, it should not be dispensed and an alternative such as codeine should be provided after consideration with the prescriber. Thirdly, according to NICE guidelines, the first line treatment for suspected UTIs include Nitrofurantoin or Trimethoprim.12 However, in the case of Mrs Gardner Trimethoprim is not the most suitable choice as it has several interactions with her current medications. One of which is the increased risk of side effects when given with methotrexate.8 Furthermore, concurrent use with Ibuprofen can result in increased risk of hyperkalaemia, hyponatraemia and nephrotoxicity.8 Due to all these contraindications, Trimethoprim should not be dispensed and an alternative such as Nitrofurantoin should be provided after discussion with the prescriber. Finally, the biological prescribed may not be the most suitable, as NICE states to start treatment with the least expensive drug.4 This may not be the case with Adalimumab as these medications are very expensive. Therefore, it is recommended by the UK office of fair trading that a “value-based approach” should be used, thereby choosing a drug which is cost effective.13 In the case of Mrs Gardner, she would need to be referred back to the GP in order to be prescribed a biological which is more cost effective based on her patient access scheme.
Principles three and four relate to the safe use of medications and making medicines optimisation part of routine practice. The RPS states that ensuring the safe use of medications is the responsibility of all healthcare professionals, healthcare organisations and patients.1 It includes all aspects of medication usage, side effects, interactions and effective communication between professionals. In order to achieve this, there has to be an effective collaboration with Mrs Gardner’s GP in terms of managing her ongoing conditions. This will involve adjustment of her current medications for RA and her UTI, but also in terms of follow-up, the patient is going to receive.14 Making medicines optimisation part of routine practice will result in a better outcome for patients with long-term conditions such as RA.15 Therefore, it is vital that both pharmacists and other healthcare professionals who encounter patients like Mrs Gardner ensure that they routinely practice medicines optimisation.