Doncaster & Bassetlaw Area Prescribing Committee October 2009 V2.0
Shared Care Proforma for the Management of Inflammatory Arthritis
& Connective Tissue Disease for Adult services, over 16
To be completed by Specialist
PATIENT DETAILS: (please complete or attach sticky label)
Name:
PATIENT’S GP:
Date of birth:
CONSULTANT DETAILS:
NHS No:
Name (PRINT)
Trust
Signature
Date
Address:
DRUG, DOSAGE AND ROUTE
Name of Drug:
Dosage:
Date of initiation
by Consultant:
Date when dosage in stabilised (usually, but not exceptionally,
after a period of 3 months)
Route:
The Shared Care Protocol V 2.0 is available on the
Medicines Management Webpage:
http://medicinesmanagement.doncasterpct.nhs.uk
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This document will be reviewed in light of new or emerging evidence or by April 2014
Doncaster & Bassetlaw Area Prescribing Committee October 2009 V2.0
MONITORING ARRANGEMENTS (to be completed by consultant)
Hospital / Specialist
 Baseline monitoring of (tick if appropriate)
 FBC  WBC  Platelets  Urinalysis
 U&Es  LFTs  Urinalysis for Proteinuria & Blood
 Differential WBC  Creatinine
 TPMT  BP  Chest X-Ray
 Continued monitoring (tick if appropriate)
 4-Weekly FBC  4-Weekly Urinalysis
 FBC, WBC & Urinalysis before each injection
 Fortnightly FBC, U&E & Urinalysis for first 3
Months then every 4 weeks
 2-Weekly FBC, WBC & LFT for first 12 weeks, then
Every 3 months for first year then 6-Monthly
thereafter (or 1 month after dose increase)
 Weekly FBC & LFTs for first 6 weeks then monthly
 6-Monthly U&Es
 Fortnightly  FBC  LFT  U&E for 6 weeks
After any dose increase
 Monthly FBC, Differential WBC, LFT & BP for
First 6 months then every 8 weeks
 Fortnightly FBC, WBC, U&Es & LFTs for first
6 weeks then monthly thereafter
 Ask patient about respiratory symptoms
GP / Practice
 Ongoing monitoring
o Side effects
o Symptom Control

Specialist GP Lead Monitoring
o Monthly FBC & LFTs
o 6-Monthly U&Es
o Ask about respiratory symptoms at
monitoring
OTHER MEDICATION
RESPONSIBILITY / ACTION IN CASE OF PROBLEMS
Contact: Office Hours – Specialist
Telephone DRI Rheumatology Tel 01302 553281
Out of hours – On-call DRI Tel: 01302 366666
.
To be completed by GP and returned to specialist
I agree to this shared care proposal and am willing to prescribe from
(Start date)
GP name (printed)
GP signature
Date
NB: Please call Specialist if further information or support is required prior to signing.
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This document will be reviewed in light of new or emerging evidence or by April 2014
Doncaster & Bassetlaw Area Prescribing Committee October 2009 V2.0
ROUTINE MONITORING TO BE CONDUCTED UNDER SHARED CARE ARRANGEMENTS
DRUG
CONSULTANT
GP
Auranofin (Oral Gold)



Side Effects
Symptom Control


Side Effects
Symptom Control

Side Effects
Symptom Control

Side Effects
Symptom Control


Side Effects
Symptom Control


Side Effects
Symptom Control


Side Effects
Symptom Control

Sodium Aurothiomalate
(Injectable Gold)


Penicillamine


Sulfasalazine


Azathiprine


Leflunomide


Methotrexate


Baseline:
FBC,WBC,Platelets,Urinalysis,
U&Es, LFTs & Urinalysis for
proteinuria and blood
Routine:
4-Weekly FBC & Urinalysis
Baseline:
FBC, WBC, Urinalysis, U&Es, LFT,
Urinalysis for proteinuria and blood
Routine (before each injection):
FBC, WBC & Urinalysis (when
stable for 8 weeks it is permissible to
work one week in arrears for FBC)
Baseline:
FBC, differential WBC, U&Es,
Creatinine & Urinalysis for
proteinuria and blood
Routine:
2-Weekly FBC, U&E & Urinalysis for
first 3 months then every 4 weeks
Baseline:
FBC, WBC, Creatinine, LFT
Routine:
2-Weekly FBC, WBC & LFT for first
12 weeks, then 3-Monthly for first
year then 6-Monthly thereafter (or 1
month after dose increase)
Baseline:
FBC, LFT, U&Es & TPMT
Routine:
Weekly FBC & LFTs for first 6 weeks
then monthly (FBC & LFT fortnightly
for 6 weeks after any dose increase)
6-Monthly U&Es
Baseline:
LFTs, U&Es, Creatinine, BP, FBC,
Differential WBC
Routine:
Monthly FBC, Differential WBC, LFT
& BP for first 6 months then every 8
weeks
Baseline:
U&Es, Creatinine, LFTs, FBC,
Differential WBC, Platelets and
Chest X-ray
Routine:
Fortnightly FBC, WBC, U&Es & LFTs
for first 6 weeks then monthly
thereafter (fortnightly for 6 weeks
after any dose increase)


Doncaster PCT Local Enhanced
Service
 Monthly FBC & LFTs
 6-Monthly U&Es
 Ask about respiratory symptoms at
monitoring
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This document will be reviewed in light of new or emerging evidence or by April 2014