Dmard monitoring guidelines and shared prescribing in primary care – is more education required?
1Rheumatology, Luton & Dunstable University Hospital, Luton, United Kingdom
Background: DMARDs remain the mainstay of inflammatory arthritis therapy. Though an effective treatment, these drugs have the potential to cause serious harm. Vigilant drug monitoring, reflected in recently updated BSR guidelines, is necessary to prevent potentially life threatening complications. National Patient Safety Agency has also issued several alerts regarding DMARDs and methotrexate overdose remains a ‘never event’. Prescribing medications, including DMARDs for rheumatology patients, is one of the chief responsibilities of primary care doctors.
Objectives: We undertook a pilot survey of regional GPs to understand their level of prescribing confidence with an aim to develop a targeted teaching program.
Methods: Based on BSR DMARD monitoring audit tool and regionally approved shared care guidelines, a focus group discussion with GP educators and CCG Medicine Optimisation Team was organised. Ten items were unanimously identified as core knowledge required for safe prescribing. A questionnaire was created based on these elements. GPs were surveyed at their educational meeting in our academic institution. Replies were compiled to ascertain their understanding of safe prescribing and troubleshooting DMARD related issues.
Results: There are 95 actively practicing GPs in the region. 41 (43%) GPs contributed to the survey. 22 (56%) were men. 27 (65%) had been practicing for 5–15 years (range <5 to >20 years). 34 (83%) regularly prescribed DMARDs. Only 15/41 (36%) felt confident in prescribing whereas 7/41 (17%) were neutral and remaining 46% did not feel confident. 49% participants were able to rightly answer questions pertaining to safe prescribing. Again most (70%) felt unable to confidently manage blood-monitoring issues such as neutropenia or abnormal liver function tests. Only four (9%) were able to correctly address the concerns related to administration of live vaccines whilst taking DMARDs. Nine GPs were unaware of avoiding trimethoprim co-prescription with methotrexate.
Conclusions: To our knowledge, this is the first survey to demonstrate that there are serious shortcomings in GPs’ understanding of safe DMARD prescribing. Lack of confidence amongst front line medical staff remains the main cause of this issue. Despite frequent education bulletins and alerts from national bodies including NICE, BSR and NPSA and active measures taken in recent past to identify better ways to address the concerns, this study highlights major knowledge gaps among everyday prescribers in primary care. Dedicated strategy and better collaboration with GPs, with focus on drug monitoring education, are pivotal to providing better care for patients prescribed DMARDs in the community.
Disclosure of Interest: None declared
Citation: Ann Rheum Dis, volume 77, supplement Suppl, year 2018, page A866