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
Improve Your Knowledge Base
As more medications enter the market, more product-specific education and knowledge are required of rheumatology practitioners and their teams. Mastering the proper technique for how each medication administration device works so providers can educate patients can be daunting, especially to new staff.
Safe administration of specialty medications must be managed and monitored, a process that involves assessing for contraindications to medication use, administering and managing risk evaluation and management strategies (REMS), knowing drug-specific monitoring requirements, and knowing the drug’s side effects.
Also, the majority of patients don’t store their biologic DMARDs at recommended temperatures, which can affect their efficacy and potential toxicity.8
Partners in Practice
Pharmacists have unique training and skills that can synergize with those of a multi-disciplinary rheumatology clinical practice. They can play a major role in medication management.9,10 Pharmacists can:
- See patients in the office for educational counseling about new medications, discussing their administration, use and storage;
- Answer medication-related questions;
- Reconcile medications;
- Check for drug-drug interactions;
- Develop and implement treatment protocols and guidelines;
- Initiate quality improvement projects;
- Monitor for and report adverse drug reactions, preventing medication errors and adverse events from occurring or getting worse; and
- Conduct immunization history screenings to ensure their administration before starting immunosuppressive drugs, such as biologics and JAK inhibitors. In one pediatric rheumatology practice, PCV-13 immunization rates improved by more than 30% following the addition of a pharmacist to a multidisciplinary team.10
It has been more than 40 years since Roberta Monson, MD, first reported that adding pharmacists to rheumatology care teams benefits the patient and provider, and the use of pharmacists in rheumatology clinics has greatly expanded in recent years with the advent of so many expensive and complicated drugs.11,12 When embedded in the clinic, pharmacists are seen as part of the healthcare team and establish relationships with patients in the practice. This relationship adds another opportunity for effective communication with the patient to enhance medication adherence.13
There is limited information about the cost effectiveness of having a clinical pharmacist embedded in rheumatology clinics. However, multiple practices, particularly those academic centers with specialty pharmacies, have successfully used this model.7,10 Having the specialty pharmacy as part of the practice can improve adherence, increase revenue and prevent losing patients to follow-up because all records are centralized.
Improve adherence: In one case, following the integration of a clinical pharmacist within a pediatric rheumatology clinic, adherence rates to injectable specialty medications were greater than 90%.10
Increase revenue: Likewise, prescriptions filled at an onsite specialty pharmacy increased following collaboration with a clinical pharmacist. In one center, this led to a 500% increase in specialty pharmacy revenue from the pediatric specialty clinic in the first year following this collaboration because more and more patients opted to fill their prescriptions with the university specialty pharmacy rather than national mail-order pharmacies. This demonstrated the model can be cost effective.10
Save time: A recent study described the use of a pharmacist to take a medication history for all new patients in a primary care practice before seeing the practitioner. Appropriate therapy was then discussed with the practitioner.14 This saved the practitioner approximately 15 minutes per new patient with the potential to increase practitioner availability. The primary challenge of this model was the coordination of the schedules of the practitioner and the pharmacist.14
Having pharmacists embedded in the clinic as part of the rheumatology care team may minimize the scheduling problem between the pharmacist and practitioner.
Sharing a pharmacist with another subspecialty is another model employed by several rheumatology clinics. Rheumatology and gastroenterology are examples of specialties that may be particularly amenable to this approach (personal observation of PJF and BHR-T).
Overcome the Barriers
Pharmacists trying to get involved in rheumatology practice do face barriers. Notably, pharmacists are not recognized as providers under Medicare Part B, which limits their ability to be reimbursed for clinical services rendered.15 States vary in their laws regulating the activities of pharmacists.
Pharmacists often have collaborative practice agreements with other practitioners that outline what they can do.16 Under collaborative practice agreements, qualified pharmacists under defined protocols may be able to perform patient assessments, provide counseling, order laboratory tests, administer drugs and titrate medications. Two useful examples are with methotrexate and urate-lowering agents.
Another barrier is having enough exam rooms for the pharmacist to meet privately with patients. The advent of telemedicine and follow-up phone calls may assist with this process.
An additional challenge is having practitioners recognize how pharmacists can benefit the practice and accept and welcome the pharmacists’ expanded role.
Adding a specialty pharmacist to a multidisciplinary rheumatology practice is one option to improve medication safety, decrease delays to medication access, increase adherence, increase revenue and improve quality measures.10,12,17 It can allow rheumatologists more time to focus on different areas of their practice.
There is a need for further study to demonstrate and document improved patient care and time and cost savings.
Polly J. Ferguson, MD, is the Margorie K. Lamb Professor, and director of Pediatric Rheumatology, Immunology and Allergy at the University of Iowa, Carver College of Medicine, Iowa City.
Jessica Lynton, PharmD, BCPS, is a clinical pharmacy specialist–pediatric rheumatology for Specialty Pharmacy Services at the University of Iowa.
Beth H. Resman-Targoff, PharmD, FCCP, is a clinical professor in the Department of Pharmacy: Clinical and Administrative Sciences at the University of Oklahoma College of Pharmacy.
- Harnett J, Wiederkehr D, Gerber R, et al. Primary nonadherence, associated clinical outcomes, and health care resource use among patients with rheumatoid arthritis prescribed treatment with injectable biologic disease-modifying antirheumatic drugs. J Manag Care Spec Pharm. 2016 Mar;22(3):209–218.
- Nasser-Ghodsi N, Harrold LR. Overcoming adherence issues and other barriers to optimal care in gout. Curr Opin Rheumatol. 2015 Mar;27(2):134–138.
- Goldfien RD, Ng MS, Yip G, et al. Effectiveness of a pharmacist-based gout care management programme in a large integrated health plan: Results from a pilot study. BMJ Open. 2014 Jan 10;4(1):e003627.
- Mikuls TR, Cheetham TC, Levy GD, et al. Adherence and outcomes with urate-lowering therapy: A site-randomized trial. Am J Med. 2019 Mar;132(3):354–361.
- FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care Res (Hoboken). 2020 Jun;72(6):879–895.
- Schondelmeyer SW, Purvis L. Trends in retail prices of specialty prescription drugs widely used by older Americans: 2017 year-end update. American Association of Retired Persons Public Policy Institute. June 2019 Jun.
- Ramey W, Lohr KM, Zeltner M, et al. Biological and targeted synthetic DMARDs’ prior authorization time is significantly reduced with pharmacy presence in the rheumatology clinic [abstract 1046]. Arthritis Rheumatol. 2017 Sep 27;69(suppl 10).
- Vlieland ND, Gardarsdottir H, Bouvy ML, et al. The majority of patients do not store their biologic disease-modifying antirheumatic drugs within the recommended temperature range. Rheumatology (Oxford). 2016 Apr;55(4):704–709.
- Flick C, Farrell J. The pharmacist’s role in managing rheumatic diseases. The Rheumatologist. 2013 Aug 1;7(8).
- Lynton JJ, Mersch A, Ferguson P. Multi-disciplinary practice advancement: The role of a clinical pharmacy specialist in a pediatric specialty clinic. Am J Health-Syst Pharm. 2020 Nov 1;77(21):1771–1777.
- Monson R, Bond CA, Schuna A. Role of the clinical pharmacist in improving drug therapy. Clinical pharmacists in outpatient therapy. Arch Intern Med. 1981 Oct;141(11):1441–1444.
- Bernstein S. Rheumatology clinics add pharmacists to care teams, see benefits. The Rheumatologist. 2019 Jan 17;13(1).
- Haskard Zolnierek KB, DiMatteo MR. Physician communication and patient adherence to treatment: A meta-analysis. Med Care. 2009 Aug;47(8):826–834.
- Bateman MT Jr., McCarthy C, Alli K. Linked pharmacist-provider new patient visits in primary care. Am J Manag Care. 2020 May 1;26(5):e162–e165.
- Gebhart F. On the road to provider status. Drug Topics. 2019 Jun 13;163(6).
- Collaborative practice agreements and pharmacists’ patient care services: A resource for pharmacists. Atlanta: U.S. Dept. of Health and Human Services, Centers for Disease Control & Prevention; 2013 Oct.
- Rowley AK, Resman-Targoff BH, Marra CA, Pucino F. Evolution of clinical pharmacy in the practice of rheumatology. Ann Pharmacother. 2007 Oct;41(10):1705–1707.