SAN DIEGO—In a presentation on what rheumatology nurses should know in their daily practice about disease-modifying anti-rheumatic drugs (DMARDs) at the 2017 ACR/ARHP Annual Meeting Nov. 3–8, Jessica Farrell, PharmD, highlighted the importance of educating and counseling patients about the range of treatments and applications for rheumatologic conditions. Dr. Farrell, a clinical pharmacist at the Center for Rheumatology in Albany, N.Y., said her clinical practice involves pharmacotherapy consults, drug information and patient/provider education related to DMARD therapies.
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Explore This IssueMarch 2018
“What I do every day involves educating my patients and assisting my providers around these medications used in rheumatic disease,” she said. That includes exploring issues of complications and safety, addressing misconceptions and doing “damage control” around misinformation while working with patients face to face and on the telephone.
Dr. Farrell outlined the complexities of the immune system and of the medications—small molecules, biologic DMARDs, synthetic DMARDs—used to treat immunologic disorders. There are a variety of targets for these therapies, including pro-inflammatory cytokines, such as tumor necrosis factor-alpha, interleukin (IL) 1, IL-6, IL-17 and IL-12/23, Janus kinase inhibitors, and T cell and B cell modulators, among others.
“There are a lot of questions about these treatments and how to incorporate them into your daily practice,” she said. Different therapies come with different means of administration, some with prefilled syringes, different dosages, different lengths of time to take effect, potential reactions to be managed, the need to rotate injection sites for subcutaneous treatments, and particular concerns regarding storage and preparation of the treatments.
Folic acid therapy can help with some side effects of treatment with methotrexate, such as nausea, and patients should be educated to stop biologic therapies when they become sick, Dr. Farrell said. Other challenges include questions of convenience, for example, patients who are afraid of performing self-injections, although their options may be limited by insurance company policies. Injection-site reactions are common. There are drug interactions to watch for and infection control concerns to consider. Sometimes, patients develop antibodies against a drug, which can cause it not to work as well or cause injection or infusion reactions.
For infection control, she recommended adopting clear policies and procedures, paying close attention to infections particular to the geographic locale and to patients’ travel history. Hand hygiene and cough etiquette are important, as are appropriate screening for hepatitis and tuberculosis and education about the risks of live vaccines. Patients need clear rules of when to stop their treatments and call their physician.