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From: The Rheumatologist, August 2013

The Pharmacist's Role in Managing Rheumatic Diseases

by Carissa Flick, PharmD, and Jessica Farrell, PharmD

Rheumatic disease treatment requires an integrated, multidisciplinary team. Adding a pharmacist to the team has many benefits, including improving patient compliance and education, providing a drug information resource, and assisting in assuring insurance coverage. The role of a pharmacist can vary greatly depending on the practice setting, but ultimately, pharmacists play a key role in supporting pharmaceutical care. This includes establishing patient relationships; obtaining medication history information; preventing, identifying, and resolving medication-related problems; dispensing medications; educating and counseling patients and healthcare providers; monitoring patient and medication effects; and ensuring continuity of care.

Where Does the Pharmacist Work?

A pharmacist may work in a variety of settings. These include a community pharmacy such as an independent or chain drugstore, a hospital pharmacy, or ambulatory-care settings such as an outpatient hospital clinic or private medical practice.

In the community pharmacy, the pharmacist is primarily responsible for counseling patients on new medications, properly filling a medication order from a prescriber, and answering questions that may arise from other healthcare providers or patients. A community pharmacist is likely the first person a patient calls to ask a question about a medication because of this professional’s easy accessibility.

Pharmacists who work in a hospital setting play a role in dispensing medications, verifying and clarifying medication orders, and mixing medications. Pharmacists in hospitals may also have a role in medication reconciliation, discharge counseling (particularly newly diagnosed patients or those starting a new medication), and working with physicians and nurses to provide direct patient care. Pharmacists may also participate in physicians’ rounds to provide suggestions on treatment options for patients with rheumatic diseases. This may be most helpful when providers are treating patients with refractory diseases, as the pharmacist may serve as a valuable drug information resource.

A pharmacist who works in the ambulatory-care setting may have many different responsibilities. The pharmacist may see patients in the office for educational counseling sessions, talk with patients about their specific drug questions, or work with providers to serve as a drug information resource.

The entry-level educational requirement for pharmacists is now a doctoral degree. Some pharmacists also go on to complete one to two years of residency training, with the majority of these pharmacists going into hospital or ambulatory-care pharmacy settings. Although there are second-year, postgraduate specialty training programs in pediatrics, oncology, infectious disease, cardiology, critical care, emergency medicine, and internal medicine, currently there are no specialty trained rheumatology programs for pharmacists. The number of residency-trained pharmacists continues to grow, although residency training is currently not mandatory for all pharmacists.1

Although there are many different career paths for pharmacists, all may have a role in providing care to patients with a rheumatic disease. A pharmacist may benefit the patient and healthcare team from behind the scenes. Some examples include answering a question about a diabetes medication during a counseling session for adalimumab, checking a medication list for drug interactions or polypharmacy before dispensing a medication, answering a drug-information question regarding a rare side effect of a biologic, or providing assistance with the insurance approval process by summarizing peer-reviewed articles for off-label use of medication.

What Roles Could a Pharmacist Play?

Over the last decade, the practice of pharmacy has expanded to include extensive clinical training. This has extended the role of the pharmacist beyond preparing and dispensing medication, and enabled pharmacists to deliver of a wide range of patient-oriented services. As part of their education, pharmacists have considerable training in scientific literature evaluation and drug information. Their skill set makes them an asset to the busy practicing clinician.

Improved patient adherence: Patient adherence to treatments for chronic diseases is often poor. For example, only 45% of patients with osteoporosis continue to take their medications after the first year.2 Medication adherence in patients with rheumatoid arthritis (RA) has also been reported as low.3

A systematic review was performed to ascertain adherence in patients with RA or systemic lupus erythematosus (SLE). This review concluded that adherence to disease-modifying antirheumatic drugs and/or biologic medications in the treatment of RA or SLE was inadequate in many patients. Adherence varied by medication, delivery, and dosing schedule, but was also dependent on sociocultural characteristics, patients’ beliefs about medications, self-efficacy, and quality of communication with the physician.4 Another study, performed by Zwikker et al, developed a group-based intervention led by a pharmacist. This intervention was a time-efficient model that helped improve medication compliance in nonadherent RA patients.3 There are also many publications documenting very low rates of adherence to gout medications, which often leads to inflammatory attacks.5

The literature shows the current issues with medication adherence in patients with RA, SLE, and gout, and suggests the importance of patient education to improve adherence and strengthen the relationship of the patient with the rheumatology team. A pharmacist can play a major role in this effort. They can educate patients about how medications work, how to take medications, and the importance of adherence. A pharmacist can also provide education about side effects by clarifying what the patient reads on the Internet or hears on TV about a medication. Pharmacists are trained to interpret and analyze literature. By utilizing this skill through a one-on-one drug-education session, a pharmacist can ease patients’ fears and help them better understand the medication and improve adherence.

Drug-information resource: Providers spend many hours a day seeing and helping patients. This time constraint makes it difficult to analyze the literature for the prevalence of a rare side effect, or know what drugs may be safely used during pregnancy or lactation. Utilizing a pharmacist allows this to be done in depth. Pharmacists are able to evaluate the literature and summarize it for the provider. A pharmacist can also document drug information in the medical record with proper references, or contact the patient directly to answer a medication-related question. This involvement is likely to improve patient communication with the rheumatology team and assure the patient that he or she is receiving optimal care. Adding a pharmacist to any practice setting will give the provider more time to spend with patients without sacrificing quality.

In addition to being a behind-the-scenes drug-information resource, a pharmacist is a medication expert. They dispense education to providers on new medications, pertinent drug interactions, or other important drug topics. Depending on your practice site, a pharmacist can offer this information formally during weekly educational conferences or informally on an as-needed basis. Pharmacists assist providers when picking an appropriate therapy regimen for a patient. A pharmacist brings a different perspective and may be able to provide unique insight when choosing the right medication for a patient.

Prior authorization insurance letters: A growing number of published reports suggest that various biologics predominantly approved for RA can be efficacious treatment options for several rare rheumatic diseases.6 Unfortunately, many practicing rheumatologists are hindered in their ability to employ these potentially effective treatments for their patients because of difficulty in obtaining coverage from insurers. In most instances, insurers deny coverage of off-label use because no double-blind, placebo-controlled studies have shown that the agent is effective for the disease being treated. As practicing rheumatologists know, this type of evidence is only infrequently available for these rare rheumatic diseases. For many of these conditions, there may not even be a single agent approved by the U.S. Food and Drug Administration to treat the disease due to its rarity. Consequently, the medical director for the insurer may not be aware of these facts or have any familiarity with the disease. The potential consequences of nontreatment, or the inadequacy of other accessible therapies, can be devastating to the patient’s care.

Pharmacists are able to analyze the literature that supports the off-label use of a medication, and summarize it in a letter that includes patient-specific characteristics and history, to prove the benefit of the medication. This is an important service, particularly because cost is often a burden for patients and can decrease compliance.

These are some of the many services and benefits pharmacists can bring to the multidisciplinary team of a rheumatology practice, and their behind-the-scenes roles can greatly improve patient-care outcomes. For additional information on the many roles of interdisciplinary team members, visit www.rheumatology.org/practice and click on “Patient Resources.”


Dr. Flick is a postgraduate year-one pharmacy practice resident at St. Peter’s Hospital in Albany, N.Y. Dr. Farrell is a clinical pharmacist at The Center for Rheumatology and assistant professor at Albany College of Pharmacy and Health Sciences in Albany, N.Y. She is currently serving as a member of the ARHP Practice Committee and the ACR/ARHP Drug Safety Subcommittee.

References

  1. Johnson TJ, Teeters JL. Pharmacy residency and the medical training model: Is pharmacy at a tipping point? Am J Health Syst Pharm. 2011;68:1542-1549.
  2. Briesacher BA, Andrade SE, Fouayzi H, Chan KA. Comparison of drug adherence rates among patients with seven different medical conditions. Pharmacotherapy. 2008;28: 437-443.
  3. Zwikker H et al. Development and content of a group-based intervention to improve medication adherence in non-adherent patients with rheumatoid arthritis. Patient Educ Couns. 2012;89:143-151.
  4. Achaval S, Suarez-Almazor ME. Treatment adherence to disease-modifying antirheumatic drugs in patients with rheumatoid arthritis and systemic lupus erythematosus. Int J Clin Rheumtol. 2010;5:313-326.
  5. Reach G. Treatment adherence in patients with gout. Joint Bone Spine. 2011;78:456-459.
  6. Ramos-Casals M, Brito-Zeron P, Munoz S, et al. A systematic review of the off-label use of biological therapies in systemic autoimmune diseases. Medicine. 2008;87:345-364.

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