Jarun Ontakrai / SHUTTERSTOCK.COM
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.
“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.
“Knowing all of these nuances as a clinician is the hardest part,” Dr. Farrell said. “There is so much for us to learn. Then to be able to put all of this information into simple terms for our patients is quite a challenge—it takes practice.” Her group has developed its own fact sheets and frequently asked questions (FAQs) specific to each treatment, drawing upon prescribing information and handouts and medication guides from groups such as the ACR, but then tailored to its setting and peer reviewed by its clinicians. Ideally, order sets with check boxes would be integrated into the electronic health record.
“If you don’t have tailored patient education handouts for your practice, I’d urge you to work on developing them. They are very helpful,” she said. “When highlighting side effects, try not to make them sound too scary. Tell patients that being educated about the risks helps them better manage their disease and potentially reduce their risk for adverse events,” she added. “We use a mix of resources here.”
Dr. Farrell also encouraged professionals to work with patients to address their questions and anxieties at every face-to-face encounter, before and after treatment is started. “I find that when patients know more about each treatment and how they work, they tend to have more confidence in their treatment plan.” Reducing patients’ anxieties also increases their compliance. It is important that patients have realistic expectations, she said. “Explain that these drugs are disease modifying, with their own methods of action and common side effects, although it can take multiple visits to reinforce this information.”
‘Knowing all of these nuances as a clinician is the hardest part,’ Dr. Farrell said. ‘There is so much for us to learn.’
Additional Challenges of Patient Education
Some DMARDs can’t be used during pregnancy. Talk to patients of child-bearing age about the different medication exposures and associated complications for each treatment—although overall risk to pregnant women is relatively low with most biologic treatments, Dr. Farrell said. Some biologics, specifically certolizumab pegol and etanercept, can be used as needed during the first trimester and then tapered or continued if disease activity remains high.
Injection-site and/or infusion reactions to some biologic treatments are common. Premedication treatment can help with those, for example, diphenhydramine and second-generation antihistamines or steroids. “We give these 30 minutes before starting some infusable biologics. Make sure you have the pre-med treatments on hand, and your protocols should absolutely include how to treat for infusion and injection-site reactions.”
Dr. Farrell also discussed newer targeted synthetic DMARDs, such as apremilast, an inhibitor of phosphodiesterase 4 used for the treatment of certain types of psoriasis and psoriatic arthritis, and tofacitinib, a JAK inhibitor. Apremilast may also be useful for other immune system-related inflammatory diseases. “But we have had a hard time getting these newer drugs approved by insurance companies. Again, clear communication with patients is needed, especially if there could be a delay in access to medication.”
It is important to titrate the dose of the medication in response to side effects, which are more intense in early stages. These include diarrhea, nausea, weight loss, headaches and risk for infection.
“I can’t not mention biosimilars,” Dr. Farrell said. “These are going to make things very interesting from an administrative perspective, generating lots of confusion. Patients need to be educated that these are coming and that their medications might get switched. For our patients, we will create FAQs regarding biosimilars.”
Larry Beresford is a freelance medical journalist in Oakland, Calif.