I am the rheumatology and biologics lead pharmacist at the Royal Cornwall Hospital, based full-time within the rheumatology department at a primary care centre close to the city centre in Truro.
I manage the day-to-day care of patients on biologic- and targeted synthetic disease-modifying antirheumatic drugs (b- and tsDMARDs), and run my own inflammatory arthritis, osteoporosis and connective tissue disease clinics.
In addition, I am the clinical governance lead for the rheumatology specialty, which involves reviewing relevant new guidelines from the National Institute for Health and Care Excellence (NICE) and collating a response from my colleagues in terms of the impact or resource needed as a result. I also lead our specialty’s programme of audits.
I work closely with the pharmacy department, as well as the rheumatology, dermatology and gastroenterology specialties, to manage biologic therapies across the trust. For example, when we switched our existing Humira (AbbVie) patients to our chosen biosimilar.
My interest in rheumatology is a result of having close family members with rheumatoid arthritis and other related conditions. While working in community pharmacy, I completed my postgraduate diploma focusing on the management of rheumatological conditions. I then moved into hospital pharmacy and have been in my current role for ten years. I have undertaken further training so that I can independently prescribe, request medical imaging, perform arthrocentesis (joint aspiration) and administer intra-articular injections.
I currently work from home but go into the office once or twice per week to sign prescriptions and complete other paperwork.
09:00 – Start
Today is Monday, and the week starts with our multidisciplinary team (MDT) meeting, now held virtually. This is attended by consultants, clinical nurse specialists, junior doctors, the research team, and occupational and physiotherapists.
We discuss patients being considered for treatment with b- or tsDMARDs, along with complex cases. My role is to make sure that proposed treatment plans are in accordance with the relevant NICE guidelines and technology appraisals. We also have a local pathway to guide our decisions when there are multiple agents to choose from with the same mode of action, such as anti-tumor necrosis factor (TNF) drugs.
At the meeting, I present a case of a patient I saw in clinic the previous week — a lady in her early 60s with rheumatoid arthritis. She had completed a six-month trial of adalimumab but with no clinical improvement. During her appointment, we agreed to consider an alternative agent. After discussion at the MDT, we opt for tofacitinib, a Janus kinase inhibitor and a tsDMARD. The patient will have a further appointment with either myself or a nurse to discuss this treatment, and it will then be initiated via one of our homecare providers.
We also discuss the most recent advice relating to the COVID-19 vaccination programme. Rituximab causes depletion of B-lymphocytes, which are involved in the immune response to vaccination, and there is some limited evidence that, generally, vaccines may be less effective depending on when they are administered in relation to rituximab. The current advice is to defer non-urgent rituximab until two weeks after completion of the COVID-19 vaccination course, or to wait four to eight weeks post-rituximab treatment before the first dose of the vaccine.
I grab a cup of tea and work through the list of patients discussed earlier in the day. Our clinical commissioning group requires us to complete funding applications for all rheumatology patients starting on Payment by Results excluded therapies, such as b- and tsDMARDs, to demonstrate compliance with NICE guidance. I complete the necessary forms and note that a couple of patients require an assessment of disease activity when they attend clinic for counselling.
I email our therapies coordinator so that she can add a note to the files for these patients to make sure the assessments are completed. Depending on the condition the patient is being treated for, the assessment can be a patient-reported outcome measure or require physical assessment of the patient’s joints to identify tenderness and synovitis (characteristic swelling seen in inflammatory arthritis).
I begin issuing repeat prescriptions for patients on homecare medicines. We receive a weekly list of requests from each of our providers and, on average, I will write 50–60 repeat homecare prescriptions every week.
For each patient, I review their recent clinic letters and blood results to check that continuation of treatment is appropriate. I also ensure follow-up appointments are booked within the right timeframe. I flag patients who have not had their required blood tests so that our administrator can send them a reminder letter. Normally, we issue prescriptions for six months’ supply to be delivered in instalments — I use our electronic prescribing system to generate outpatient prescriptions for homecare patients, save them as PDF files, and then print and sign them when I come into the office.
Use of electronic prescriptions for homecare prescribing would be much more efficient, but this is not currently an option.
I have issued 15 repeat prescriptions this morning and will continue to work through the list throughout the week. I decide to stretch my legs and take my dogs for a quick walk into the village to grab a Cornish pasty for lunch.
I have six patients booked into my clinic this afternoon. In these clinics, I counsel patients on medication, monitor their response to treatment and adjust doses if needed. Clinic patients may be on b- or tsDMARDs but might also be newly-diagnosed and starting treatment with their first DMARD, usually methotrexate.
Owing to the pandemic, my clinics are now telephone-only. Some of our patients make round-trips of more than 100 miles to attend clinic so for stable patients, in particular, remote consultations make sense. Each appointment is 30 minutes and, afterwards, I will dictate a letter and request any required investigations or referrals (e.g. to occupational therapy).
The majority of today’s patients are already established on bDMARDs and stable, so we agree to continue treatment until their next review, usually every 6–12 months.
One of my patients has psoriatic arthritis, which we have been treating with adalimumab for the past five years. Today, I am informing him about changes to his treatment after he reported that adalimumab does not seem to be as effective as it used to be, with his symptoms returning a few days before his next injection is due. Around 30% of patients with inflammatory arthritis treated with bDMARDs will experience secondary failure after at least six months in remission. In some patients, it results from their immune system treating the drug molecule as an antigen and producing antibodies that neutralise it. Over time, the level of anti-drug antibodies increases and the drug becomes less effective.
I had previously requested he get his bloods taken at his GP surgery to check trough levels of adalimumab and the level of anti-adalimumab antibodies. Results can take 14–21 days to come back but are useful in deciding which treatment to use next. If the patient has high levels of anti-drug antibodies, a different bDMARD from the same class would be trialled as the antibodies are drug-specific; therefore, switching to a different molecule would overcome this. If the patient has low or undetectable anti-drug antibodies, they would usually be switched to a drug with a different mechanism of action.
The patient had an undetectable trough level of adalimumab and very high antibody levels, so I presented him at an earlier MDT and the team agreed to switch him to etanercept, which also targets TNF.
I counsel the patient on the change in therapy and answer any questions he might have.
After clinic, I review the letters I dictated in the previous week and authorise them to be sent to the GP. I also review the results of any investigations I have requested; there are no unexpected abnormal blood results that I need to act on.
I request an ultrasound scan of the hands and wrists of a patient who had normal radiographs — a Doppler ultrasound can be used to measure blood flow to the synovial tissue and, if this is increased, it can indicate active inflammatory disease. This patient had ongoing joint pain and stiffness but no palpable swelling and normal inflammatory markers. If the ultrasound scan is normal, escalating DMARD therapy is unlikely to be helpful and we will need to consider other options instead.
I have booked a day’s leave tomorrow to work on a research project for my professional doctorate, so I set my out-of-office reply before logging off for the day.
Are you interested in a similar role?
- Most rheumatology pharmacist posts are Agenda for Change band 7 or 8a;
- Ideally, you would have completed your postgraduate diploma and independent prescribing qualification, although it may be possible to undertake a prescribing course while in post;
- You need to be friendly, approachable and able to develop a good rapport with patients, particularly if working in a role that requires you to see patients in clinic;
- Be open to opportunities as they arise and use them to develop your own path. Learn from your colleagues as much as possible, both in terms of knowledge about conditions and soft skills, such as managing difficult consultations;
- Do not be afraid to admit that you do not know the answer to a patient’s question; usually they will appreciate your honesty and be happy for you to seek advice from a colleague or get back to them with an answer later.