Biologics and homecare in rheumatology pharmacy

Rheumatology specialist pharmacist Kalveer Flora started her work in rheumatology when the first biosimilar for rheumatology was launched in 2017. At that time, biosimilars were relatively new, and there was a need for a “pharmacy or pharmacist champion” to support clinical teams with their early introduction. She identified a “niche area,” in the early inflammatory arthritis clinic, where pharmacist support could significantly improve patient throughput. From these beginnings her specialist role has developed to encompass a wider brief including the role of lead pharmacist for the rheumatology Clinical Reference Group (CRG) for NHS England.

In rheumatology, treatment often begins with disease-modifying anti-rheumatic drugs (DMARDs)5. When patients do not respond adequately or their disease progresses, treatment is escalated to biologics or advanced therapies, explains Ms Flora. The introduction of biologics has “revolutionised” treatment for patients, she says. They have been described by patients as life-transforming, fast-acting, controlling disease, and getting patients into remission quickly.

The rapid development of biosimilars over the past five years has had a significant impact. Unlike simple generics such as paracetamol or aspirin, biologics and biosimilars are large, complex molecules that require complex manufacturing processes. They are not direct copies of the originator molecules and for this reason they are called “similar”. However, their clinical effects are the same as the originator drugs’. Indeed, biosimilars are clinically equivalent and now considered interchangeable with their originator biologic medicines, says Ms Flora. Biosimilars have widened access to treatment for patients; for example, NICE guidelines have allowed patients with moderate rheumatoid arthritis to access these medicines earlier than was previously possible. Furthermore, biosimilars cost less than the originators, enabling the NHS to provide more cost-effective services, she explains.

Optimising treatment is a key aspect of the specialist pharmacist role, particularly once patients are stable or in remission on a biological DMARD (bDMARD). Guidance suggests that, at this stage, the dosage of bDMARDs can be reduced either by lengthening the interval between doses or reducing the dose. For tablets, reducing the dosage is typically easier, while for prefilled injections (many biologics), the dosage is fixed. Therefore, in clinical practice, dose optimisation for injectable biologics often involves extending the dosing intervals. For example, a monthly injection could be extended to every second month.

Dose reduction or interval extension can be driven by both clinicians identifying stable patients and patients proactively seeking to take less medication. Patients may wish to reduce their medication burden and potential long-term risks. Feedback from patients indicates that they often feel empowered and listened to when involved in these decisions, and many are happy to inject less frequently, explains Ms Flora. While dose optimisation is encouraged in remission, stopping treatment abruptly is generally not recommended. Clinical evidence shows that simply stopping biologics is likely to cause a patient’s disease to flare. Slowly tapering the dose or extending the interval reduces this risk, helping to keep patients well.

Homecare

Homecare services ensure that medicines, including injections and even tablets, are delivered directly to the patient’s doorstep, eliminating the need for frequent hospital visits to collect medications. For new injectable treatments, a trained professional, often a nurse, visits the patient’s home to provide counselling, instructions on how to take the medicine, things to look out for, and training on administration. Homecare also frees up hospital resources for patients who require in-hospital care, says Ms Flora. Medicines delivered via homecare can sometimes be cheaper due to VAT regulations. Moreover, homecare also indirectly supports sustainability efforts by reducing patient travel to hospitals and potentially using less plastic over the long term if dose intervals are extended, she adds.

Rheumatology pharmacy

A rheumatology specialist pharmacist’s work is very varied. About 80% of the role is clinical or patient-focused, involving activities like overseeing biologic services to ensure safety and access, managing prior approval for funding from Integrated Care Boards (ICBs), and supporting patients from different areas. Ms Flora is also heavily involved in shared care, supporting access to medicines across the interface between hospitals and GPs. She also works closely with the multidisciplinary team (MDT), supporting nurses, allied health professionals, junior doctors, and consultants and participating in MDT meetings to review patients, discuss funding issues, and address barriers to treatment. In addition, the role includes supporting and training junior pharmacy colleagues and contributing to service improvement and audit.

For pharmacists considering a career in rheumatology or high-cost drugs, Ms Flora offers several tips: be inquisitive about complex cases, be visible, and form strong professional relationships within the MDT. Networking is highly valued, as “your network is your net worth”. To young pharmacists contemplating this path, the advice is simple: “just try it”, she says. The field is varied, with many different conditions and constant changes, making it a rewarding career choice.

The role of the rheumatology specialist pharmacist is integral to optimising the use of advanced therapies, improving patient outcomes, enhancing access to care, and contributing to the sustainable delivery of rheumatology services.

About Kalveer Flora

Kalveer Flora leads the rheumatology specialist pharmacy service at London Northwest University Healthcare Trust. She also serves as the lead pharmacist for the Clinical Reference Group (CRG) for NHS England.  She chairs Rheumatology Pharmacists UK which is a group of specialist pharmacists and pharmacy staff working within the space of rheumatology and biologics and she is co-chair of the Sustainability Special Interest Group (SIG) of the British Society of Rheumatology.  Kalveer Flora’s work embraces a variety of different aspects “but essentially it’s overseeing the rheumatology services to patients and that can be a wide range of inflammatory conditions”, she says.

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.