Tackling polypharmacy in rheumatology clinics

Consultant Pharmacist Hilary McKee runs regular rheumatology clinics at Antrim Hospital in Northern Ireland. She is an independent prescriber and much of her work involves review and fine-tuning of treatment for patients with inflammatory arthritis. In this interview she describes some of the challenges of drug therapy in rheumatology, the benefits of optimised treatment and why pharmacists should specialise in this area.

Ms McKee’s rheumatology work started when she joined a rheumatology consultant’s ward round where she answered medicines-related queries. Soon after she was asked to manage the supply of the newly-launched leflunomide and later developed a service for training people to self-inject methotrexate. By the time independent prescribing for pharmacists became a reality, the foundations for a fully-fledged clinic role were in place. She now holds four clinic sessions each week.

The key points from this interview are summarised below:

Challenges of polypharmacy in rheumatology

Polypharmacy – the use of multiple medicines – can be a problem in rheumatology as additional medications are prescribed to deal with side-effects from disease-modifying anti-inflammatory drugs (DMARDs).  This situation is often described as a ‘prescribing cascade’. “Actually, the most drugs I ever saw a patient on were 42 medications …. and that was just because things had kept being added, and nobody had looked to stop anything”, says Ms McKee. Another important aspect of polypharmacy is the potential for wastage. As medications account for about 25% of the NHS’s carbon footprint, reducing unnecessary medication use could have an important environmental impact and contribute to the ‘greener NHS’.

Methotrexate treatment

People can be hesitant about the use of methotrexate because of its potential for toxicity, in particular, immunosuppression. However, the doses used in rheumatology are lower than those used in cancer treatment and patients are carefully monitored “The aim, as we tell our patients, is to spot a problem before it becomes a problem”, says Ms McKee.

Cannabis derivatives in rheumatology

Many rheumatology patients purchase cannabis derivatives on the internet and they frequently mention this during consultations. The benefits of cannabis in rheumatology are not yet clinically proven.

Medication Adherence

Adherence can be an issue – and it might be suspected if a patient does not get the expected results with a prescribed treatment. Sometimes patients are misinformed about side-effects by neighbours or information in the press or internet and do not take their treatment as a result.

Role of Biological DMARDs

The introduction of biological DMARDs, starting with infliximab in about 2000, has revolutionised the treatment of inflammatory arthritis. “The biologics are very powerful drugs; they aim to stop the disease in its tracks and with that we prevent joint damage on down the line”, says Ms McKee. Many of the joint deformities that used to be common are now rarely seen.

Once a patient’s disease is stable the dose can be reduced and this is usually done by ‘dose extension’ i.e. lengthening the gaps between doses rather than reducing the dose amount. Some patients can be hesitant about dose extension out of fear of a flare. Simply stopping the treatment will usually result in a flare up of the disease.  Dose adjustment always requires individual assessment and sometimes off-label prescribing is necessary.

Working in the clinic

Working in the clinic calls for a capacity to ‘think on your feet’ says Ms McKee, because you can be faced with the unexpected. For example, a patient whose disease was stable on biologics mentioned in passing that she had developed night sweats. “Well, that’s a red flag immediately. You can’t let that patient go out of the door without investigating”, says Ms McKee.  Investigations were required to exclude tuberculosis and cancer.  Another example was a clergyman whose disease was well-controlled on methotrexate. He was planning to go to Africa for missionary work and asked about getting a yellow fever vaccine. As this is a live vaccine, methotrexate has to be discontinued for three months before it is given. When this was explained he decided that the risk of a flare was too great and he decided against going to Africa.

It is important to be willing to evaluate the response to treatment critically and standard treatment guidelines are useful but guidelines are black and white, whereas patients are not. “They’re grey, they’re complicated and you need to think outside the box”, she says.

Tips for success

Two key tips are – “be aware of your own limitations” and “know your drugs inside out”. Prescribing in rheumatology is complex and patients have many comorbidities; it is a specialty with many opportunities for pharmacists.  “Get in there and just do it” advises Ms McKee.

ESCP Workshop

In October 2024 Hilary McKee and Kalveer Flora ran a workshop at the ESCP Symposium in Krakow, Poland, at which they described their work as independent prescribers and invited the audience to think about how they might tackle some of the common problems that arise in rheumatology clinics.