The number of medications with rheumatologic indications has increased in parallel with expanding complexities of medication approval and delivery. Simply starting a patient on a biologic medication or new disease-modifying anti-rheumatic drug (DMARD) can be time consuming and frustrating for physicians, nurses and their support staff.
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Explore This IssueNovember 2020
In addition to educating the patient and obtaining prior authorization, the rheumatologic care provider must understand limited distribution and patient assistance programs, keep up with frequently changing reimbursement structures and learn basic knowledge about the mechanism of action, indications, administration, drug interactions, monitoring and safety concerns for new medications.
Further, for those patients with rare disorders that require off-label use of expensive medications, simply obtaining permission to use a medication can take weeks or longer.
Even after all that effort, adherence to a prescribed medication regimen is often a major problem. For example, between 41 and 75% of patients with rheumatoid arthritis are nonadherent with their DMARDs.1 Patients reported stopping or not starting biologic DMARDs because of their cost, efficacy concerns or side effects.
Studies have shown that the use of a pharmacist can improve adherence in patients with gout.
Adherence to urate-lowering therapy is reported to be very poor, at 10–46%.2 However, a pilot gout management program for patients starting or not at goal with urate-lowering drugs had a pharmacist work with a rheumatologist to manage therapy.3 The pharmacist interacted with the patients by phone to provide education, ordered laboratory tests and adjusted medications according to a protocol. Seventy-eight of 95 patients who completed the program had consecutive serum uric acid measurements achieving the ACR recommended goal (less than 6 mg/dL). The pharmacist spent six to eight hours per week managing 80 patients, and the rheumatologist spent less than 30 minutes per week providing supervision.3
Another one-year, site-randomized trial in patients with gout initiating allopurinol showed that a pharmacist-led intervention program produced superior results vs. usual care.4
The 2020 ACR Gout Guideline states that “for all patients taking urate-lowering therapy, we conditionally recommend delivery of an augmented protocol of urate-lowering therapy dose management by non-physician providers to optimize the treat-to-target strategy that includes patient education, shared decision making and treat-to-target protocol.”5
Streamline Prior Authorization
The average cost of specialty prescription medications continues to rise at an alarming rate. According to a 2017 AARP report, specialty drug prices increased three times faster than the general rate of inflation and the average annual cost for a single, specialty medication was nearly $79,000.6 Moreover, obtaining prior authorization for these expensive medicines is more complex, taxing the rheumatology staff and decreasing job satisfaction as the process consumes more and more of their valuable time.
Research shows that a pharmacist decreased the prior authorization time from 52 days to 6.43 days.7