Clinical pharmacy services in the dermatology biologics clinic
Kläre Bryant, advanced clinical pharmacist in dermatology at Liverpool University Hospitals, was a recently-qualified independent prescriber when she managed the switch to biosimilar infliximab for the cohort of dermatology patients who were receiving the drug. Clinics for patients receiving biologic and other systemic treatment were the next logical step for her.
Over time her role in the clinics has developed and become more specialised. After managing the switch to the biosimilar drug, she continued to monitor the infliximab cohort of patients. She routinely undertakes therapeutic monitoring – infliximab trough levels and anti-infliximab antibody levels – for this group of patients. She also works in the dermatology inpatient ward and the day-case area where patients receive infliximab infusions and so she is involved in the whole patient journey.
Monitoring of patients receiving systemic therapies follows the schemes set out by the British Association of Dermatologists. Local templates have been developed that incorporate all the BAD guidance and checklists are used to ensure that all the relevant questions are asked and tests ordered. Routine blood monitoring includes a full blood count and liver function tests. Patients receiving methotrexate may also need PNP (type III procollagen peptide) and FibroScan monitoring at times, says Ms Bryant. In addition, checks are made for signs of infection, that patients are up-to-date with vaccinations and that they are tolerating their treatment. Clinic visits also provide an opportunity to have a discussion with the patient about treatments and make adjustments if necessary.
As part of the assessment in the clinic Ms Bryant will examine the patient’s skin, estimate the psoriasis area and severity index (PASI) score and the dermatology life quality index (DLQI) score. A PASI score is important when systemic treatments are started (and is required by some NICE guidance) and is also important for monitoring the response to treatment, she explains.
During the coronavirus pandemic much of the clinic work was switched to telephone consultations. Ms Bryant explains: “We were able to do telephone consultations especially for follow-up patients for monitoring. So, I continued with my clinics as normal – almost normal – but doing it on the telephone. The only thing that I wasn’t able to do, obviously, is do that skin examination for the patient. So, it was very much relying on patients telling us what was going on with their skin. Knowing the patients anyway I found that that was OK ….. and patients are very good at describing what’s going on with their skin as well and I had quite a bit of experience in my role by then so I was able to fully understand what the patients were describing to me.”
Isotretinoin
Isotretinoin clinics are also run by some pharmacists who have specialised in dermatology. “I think this is a good role for pharmacists to do the isotretinoin monitoring for the clinics. It’s really important to have the time to spend with the patients to be able to explain about the medication and the importance of taking it regularly and the importance of doing the monitoring – and especially the pregnancy prevention programme for the ladies of childbearing age. Pharmacists and the specialist nurses are in a very good position to have the time to explain that advice to patients”, says Ms Bryant. Moreover, given that patients enrolled in the pregnancy prevention programme need to have their prescription renewed every four weeks, this provides a natural point for monitoring.
Kläre Bryant is an advanced clinical pharmacist in dermatology at Liverpool University Hospitals NHS foundation trust. She has an outpatient clinic at Broadgreen Hospital for patients receiving biologic therapies and another clinic at Aintree hospital for patients receiving systemic disease modifying anti-rheumatic drugs (DMARDs)
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