Involving pharmacists in the management of chronic diseases benefits patients, says Wendy Ramey, BSPharm, RPh, CSP, a clinical pharmacy specialist in rheumatology at the University of Kentucky, Lexington. She knows this personally. As someone with rheumatoid arthritis (RA), Ms. Ramey knows pharmacists can play an important role in patient education and encouraging adherence to medications.
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Ms. Ramey is one of many pharmacists across the country who work with rheumatologists as part of a multidisciplinary team, a trend expected to increase in the coming years as more pharmacists align themselves with specialty practices.
Donald Miller, PharmD, professor of pharmacy practice at North Dakota State University, Fargo, and a member of the ARP, says the topic of adding pharmacists to rheumatology care teams was the topic of a popular session at the 2018 ACR/ARHP Annual Meeting.1
“With the growing shortage of rheumatologists, I believe we will see pharmacists continue to bridge the gap between rheumatologists and patients,” says Dr. Miller. “Pharmacists are a critical part of a patient’s treatment plan. They provide education, monitor diseases and help manage medication side effects and complications—all things that are often hard for physicians to cover in a 15-minute appointment.”
The Rheumatologist spoke to pharmacists who work closely with rheumatologists to determine how rheumatologists can better utilize them in their practices and ways the two can work together to provide better patient outcomes.
Align Your Practice with a Pharmacist
Adding a pharmacist to a rheumatology practice, either on site or on a consulting basis, can offer many benefits by improving patient compliance and education, resolving medication-related issues and ensuring continuity of care, says Dr. Miller.
Brett Glasheen, PharmD, clinical pharmacist, rheumatology and gastroenterology at University of Utah Health, Salt Lake City, sees a growing trend of pharmacists joining rheumatology clinics, although the majority of growth is still seen at the academic level.
“Funding a pharmacist can be an issue for rheumatologists in private practice,” Dr. Glasheen says. “In academic settings, the cost of a pharmacist is often covered in the pharmacy budget, but for other rheumatologists, it might be beneficial to align their practice with pharmacy services in the local community.”
Jessica Farrell, PharmD, an associate professor of pharmacy practice at the Albany College of Pharmacy and Health Sciences, N.Y., offers an example of this alignment. In 2018, Dr. Farrell pioneered a training program that places a second-year postgraduate pharmacy resident on site in the Center for Rheumatology in Albany.
“At the Center for Rheumatology, patients receive a separate visit with (or a phone call from) the pharmacist regarding new [biologic disease-modifying anti-
rheumatic drug] (DMARD) treatment,” Dr. Farrell says. “We find having the pharmacist cover the details of medication therapy separately saves the rheumatologist a lot of time and allows the patient to feel more comfortable and confident.”
‘Pharmacists are a critical part of a patient’s treatment plan. They provide education, monitor diseases & help manage medication side effects & complications—all things that are often hard for physicians to cover in a 15-minute appointment.’ —Donald Miller, PharmD
Providing Enhanced Education to Patients
During a rheumatology appointment, a lot of information needs to be covered in a short amount of time, and Dr. Miller says it’s not uncommon for patients to think of additional medication questions after they’ve left their appointment. By providing medication counseling and education, pharmacists can help bridge the gap between patients and rheumatologists.
Because pharmacists are well educated in both prescription and over-the-counter medications, Dr. Miller says they can help patients better understand their prescriptions, answer specific questions and address any concerns.
“Since rheumatologists often have limited time with patients, they might not be able to address all of the questions a patient has about their medications,” Dr. Miller says. “For example, many RA patients who are starting methotrexate for the first time want to know about potential side effects, how long it will take for the medication to start working and the difference between methotrexate pills and shots.”
Assisting with Prior Authorizations
Dr. Miller says another way pharmacists can free up physician time is by assisting with the prior authorization (PA) process for prescription medications.
“The process of obtaining a PA can be very time consuming,” Dr. Miller says.
Pharmacists assist in the process, and Ms. Ramey says they can also speed up the process.
“In a retrospective review of patient records followed in the rheumatology clinics at the University of Kentucky, we found that adding a pharmacist to initiate and track the PA process decreased the time to PA from 52 days to 6.43 days,” Ms. Ramey says, citing an abstract that she and her colleagues presented at the 2017 ACR/ARHP Annual Meeting.2
Assisting with the PA process also allows pharmacists to determine if the patient is able to afford the medication, says Dr. Farrell.
“We try to find the right balance between the right medication for the patient based on their clinical status and the affordability of their insurance,” she says.
Thanks to the expansion of electronic prior authorization (ePA) by the National Council for Prescription Drug Programs, many pharmacists can now electronically initiate and handle pre-approval or prior authorization (PA) with health plans in real time, which expedites the dispensing of prescriptions.
Easing Side Effects
In addition to providing patient education, Ms. Ramey says pharmacists can also offer patients injection training and answer specific questions about drug interactions, appropriate dosage, and how to store and take the medication.
“We ensure patients are getting correct information while also offering them tips on how to handle potential side effects,” says Ms. Ramey. Example: To relieve injection site pain, she often advises patients to try warming the site area first with a hot wash cloth and then gently massaging the area after giving themselves an injection.
Dr. Glasheen often encounters patients reporting gastrointestinal side effects that come with taking methotrexate.
“Problems such as nausea and vomiting are common with methotrexate, but interventions such as switching to subcutaneous administration, ensuring folic acid adherence or altering administration time may improve tolerability,” Dr. Glasheen says.
Addressing Medication Adherence
Medication non-adherence is a major cause of morbidity, especially in elderly patients. Approximately 10% of hospitalizations may be a result of medication nonadherence.3 Several studies have shown medication adherence in patients with RA to be low.
Ms. Ramey says it’s not uncommon for patients to skip medications because of their cost.
“We mention the price of the drug before the patient does,” Ms. Ramey says. “If the cost of the medication is an issue, we work with them to find a way to make it affordable, which might involve finding a less expensive or generic medication or tapping into a prescription assistance program.”
Knowing that unintentional adherence issues often result from missing a dose or forgetting to refill a prescription, Ms. Ramey and her colleagues take a proactive approach, initiating calls with patients every month when they are due for a prescription refill.
“Our staff will ask patients if they have missed any doses and whether they have any questions for the pharmacist,” Ms. Ramey says. “We can also offer ideas to remind them to take their medications, whether that’s by keeping their prescription bottle by their toothbrush or using a smartphone app pill reminder.”
Pharmacists also provide rheumatologists with a valuable ally in combating the opioid epidemic because they are often the first to suspect a patient may be abusing or misusing their medication.
“We help patients taper off opioid use and find alternative medications,” Dr. Farrell says. “We’ve been receiving more requests about this and are working to find an efficient way to handle these patients since it can be a time-consuming consult.”
Research published this past year showed opioids were no better at controlling chronic back or osteoarthritis pain than non-opioid drugs, such as Tylenol or Motrin. The study noted this is important information for rheumatologists who may be considering prescribing opioids.4
Improving Vaccination Rates
Because pharmacists are familiar with vaccine recommendations, they can also help improve vaccination rates among rheumatology patients, says Dr. Glasheen. Despite the higher risk of acquiring an infection, vaccination rates among people with rheumatic diseases are often low.
“People with autoimmune inflammatory rheumatic diseases have a weakened immune system because of the medications they take and the disease itself,” says Dr. Glasheen. “As a result, they are more likely to get infections, such as pneumonia.”
Often the problem among patients is lack of awareness. If a patient’s primary physician doesn’t recommend vaccines against shingles, pneumonia or influenza, for example, the patient may not realize they should receive a vaccination.
Dr. Glasheen says pharmacists can determine when a patient may need a specific vaccination, ensure patients are up to date on immunizations and provide increased accessibility and availability to vaccinations by administering them in the pharmacy setting. Pharmacists can also remind patients to speak to their doctors before getting a live vaccine, such as the shingles vaccine, if they are using a biologic.
Linda Childers is a health writer located in the San Francisco Bay Area.
Think About It
Pharmacists can …
- Discuss the details of medication therapy with patients and answer questions about drug interactions, appropriate dosage, how to store and use medications, and more;
- Assist with obtaining prior authorization from insurance companies for prescription drugs;
- Offer injection training to patients;
- Offer patients tips to avoid or manage side effects;
- Help patients avoid non-adherence issues; and
- Improve vaccination rates.
- Miller D, Biehl A (moderators). Integrating pharmacists into the workforce: A session at the 2018 ACR/ARHP Annual Meeting. 2018 Oct 22.
- 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]. Arthritis Rheumatol. 2017;69 (suppl 10).
- Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy. 2014 Feb 20;7:35–44.
- Krebs E, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. JAMA. 2018 Mar 6;319(9):872–882.