DMARDs Change Package 2017/2018 - Ko Awatea
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DMARDs Change Package – 2017/2018
Aim: 100% of patients on Disease Modifying Anti-Rheumatics Drugs (DMARDs), particularly Methotrexate and Azathioprine, have their drugs safely prescribed and reliably monitored Introduction While clinically effective, cytotoxic medicines such as methotrexate and azathioprine require careful prescribing and regular monitoring to ensure patient safety and minimise risk. There have been deaths attributable to methotrexate use in New Zealand and around the world involving patients taking methotrexate as a daily, rather than weekly dose due to patient, clinician and/or pharmacy error.1,2,3 DMARDs Care Bundle Measures Identify 10 patients per month who are being prescribed either azathioprine or methotrexate. Review the notes for the following interventions: Measure 1: Appropriate tests carried out in the correct time scale Has there been a full blood count in the past 12 weeks (AZA) / 8 weeks (MTX) as per local guidance? Measure 2: Appropriate action taken for any abnormal results If any abnormal results in the previous 12 weeks (WBC
1. Identify patients who are being prescribed either azathioprine or methotrexate. Searches have
been developed to help identify these patients using your clinical systems. More information is
available online at http://www.safetyinpractice.co.nz
2. From the identified list of patients prescribed azathioprine or methotrexate, randomly select a
sample of at least 10 patients to assess against the following criteria:
− Appropriate tests carried out in the correct time scale
− Appropriate action taken for any abnormal results
− Blood tests reviewed prior to prescription
− Appropriate immunisation
− Review of adverse effects
− Patient information
3. Print and complete the DMARDs Audit Paper Form – included in the SiP DMARDs care bundle
spreadsheet and online at http://www.safetyinpractice.co.nz
4. Transfer the data collected to the DMARDs audit spreadsheet. Please make sure the date is
entered beside each individual record. The data will automatically be collated and displayed on
the run charts, which can be printed as needed
5. Save the spreadsheet
6. Email the completed spreadsheet by or on the 10th of each month (i.e. June data is due on 10
July, July data is due on 10 August).
The spreadsheet is to be emailed to roxanne.leech@middlemore.co.nzDMARDs Bundle Rationale
Measure Rationale Source
As with other DMARDs, General Practitioners
provide a DMARD monitoring service for patients
receiving these medicines. Current
recommendations are weekly or fortnightly blood
Appropriate tests tests whilst dose escalation is in progress and for 6
are carried out in weeks after the last dose alteration.
BPAC guideline for
the correct time
DMARD therapy
scale. Has there AZA – BPAC monthly monitoring once stable
been a full blood http://www.bpac.org.nz/BPJ/2008/October/dmards.
www.bpac.org.nz/
count in the past 12 aspx NZF at least every 3 months once stable
BPJ/2008/October
weeks (AZA) / 8 http://nzf.org.nz/nzf_4729
/dmards.aspx
weeks (MTX) as per
local guidance? MXT – monitoring every 4-8 weeks once stable
A letter from secondary care should document
where monitoring is longer than a six week period
e.g. the patient is stable.
Action to be taken if:
Appropriate action See table in
taken for any • WBCMeasure Rationale Source
Methotrexate is an immunosuppressant and See table in
increases the risk infections, even with a normal SafeRx bulletin
blood count. Therefore it is recommended that page 4 with
Appropriate patients should have Annual Influenza immunisation actions to be
immunisation. Is and Pneumococcal vaccine every 5 years taken
there evidence that www.saferx.co.nz/
the patient has had Patients commencing parenteral methotrexate full/methotrexate.
or declined an normally will have been taking oral methotrexate so pdf
influenza vaccine in vaccinations should be up to date, however
the past 12 months? vaccination status should always be confirmed prior BPAC guidance
to therapy commencing by the physician initiating www.bpac.org.nz/
this therapy. Due to the immunosuppressive action BPJ/2008/October
of methotrexate, “Live” vaccines should be avoided. /dmards.aspx
BPAC guidance
Patient asked about
any side effects People prescribed DMARDs require close monitoring
www.bpac.org.nz/
following last time for adverse effects and drug interactions
BPJ/2008/October
blood was taken.
/dmards.aspxTheory of Improvement
Change Ideas Tested
• Template to record the monitoring and prescribing of these patients
• Recall systems so patient return to have their blood tests taken
• Ensuring patients are invited for influenza and pneumococcal vaccines
• Using Patient information leaflets from Safe Rx
• A variety of ways of ensuring patients have the regular blood tests, i.e. letters texting emailing
• Training health care assistants to ask about side effects of the drugs.
Benefits/Positives
• Better systems for recalling patients
• Improved recording of review of blood test results prior to issuing prescription
• Patients better informed of risks and need for monitoring
• Patients highlighting significant side effects earlier
• More patients being immunized appropriately
• More consistencies in when patients are expected to have blood test taken.
Issues/Negatives
• Not many patients on Methotrexate but applying the systems to patients on other drugs
needing monitoring.Resources
Identifying Patients
Patients being prescribed Methotrexate and Azathioprine can be identified from searching your
Clinical systems. Searches have been developed for this purpose and can be downloaded from the
Safety in Practice website http://www.safetyinpractice.co.nz
Template
A generic template to help with managing patients being prescribed Methotrexate and Azathioprine
will be developed with you and the team.
Monitoring Search
Dr Info has also developed the following searches to help practices identify patients who are not
receiving regular blood monitoring
Patients prescribed Methotrexate or Azathioprine in the past 3 months and
• No full blood count tests done in the last 3 month
• No Liver function in the last 3 month
These searches can be found under the Safety tab in Dr Info
Guidance
Health pathway
BPAC guidance can be found at:
www.bpac.org.nz/BPJ/2008/October/dmards.aspx
Health Pathway guidance can be found at https://aucklandregion.healthpathways.org.nz
SafeRx Methotrexate Bulletin Safe Prescribing, once a week. May 2014
www.saferx.co.nz/full/methotrexate.pdf (Accessed 30-05-17)
Patient Resources
SafeRx Patient Information can be found at:
Safe RX has developed patient information leaflets on methotrexate:
http://www.saferx.co.nz/methotrexate-patient-guide.pdf
Highton J, Harrison A, Grainger R. Rheumatoid arthritis – monitoring of DMARDs. Best practice
journal 2008; 17:22-26 www.bpac.org.nz/BPJ/2008/October/dmards.aspx (Accessed 30-05-17)
References
1. http://www.bpac.org.nz/BPJ/2014/October/safer-prescribing.aspx
2. http://www.bpac.org.nz/BPJ/2011/february/docs/bpj_34_methotrexate_pages_16-17.pdf
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