A joint venture between the rheumatology & pharmacy departments
Standard operating procedures for rheumatology pharmacists working with
the DMARD/Anti-TNF monitoring team.
Aim: 1. To monitor the acceptability, efficacy and toxicity of disease modifying antirheumatic drugs (DMARDs) and anti-tumour necrosis factor  agents (AntiTNFs)
2. To support the patient by providing any additional drug information required.
3. To encourage good prescribing practices.
4. To provide a model for cross sector working between primary and secondary
care health care professionals.
5. To provide clinical education in the areas of DMARD/Anti-TNF monitoring and
medication review.
Type of service
A primary care based rheumatology drug monitoring and information clinic.
Staffed by rheumatology pharmacists and rheumatology nurse specialists,
supported by rheumatology consultants. This service is primarily aimed at high
risk patients with complex polypharmacy.
Role of Service
1. To accept appropriate referrals (see below for referral pathway) for monitoring
and dose adjustments of the following agents.
 The DMARDs azathioprine, ciclosporin, sulphasalazine, penicillamine,
Sodium aurothiomalate, auranofin, methotrexate (including sub cutaneous
products), hydroxychloraquine and leflunomide).
 The Anti-TNFs etanercept and infliximab.
2. To monitor and make recommendations for dose adjustments of the drugs
mentioned above, in accordance with the RheMOS drug monitoring system.
3. To review the patient’s drug history and make recommendations to promote
rational, effective and safe prescribing.
4. To educate and inform patients regarding their current or potential
DMARD/Anti-TNF therapy.
5. To maintain documentation.
6. To assist in the clinical education of other health care professionals.
Stewart E. Glaspole MRPharmS
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Referral procedure to rheumatology pharmacist drug monitoring clinic
The rheumatology pharmacist clinic runs one morning per week at either the
Preston Park development, Rheumatology Outpatients, BGH, or Hove Polyclinic
along-side a rheumatology nurse specialist. Rheumatology nurse specialists,
consultants and GPs may all refer into the service, but patients must satisfy two
of the following four criteria before a referral is accepted.
1. The patient is 60 years old or above.
2. The patient has two or more co-morbidities in addition to the presenting
arthropathy.
3. There is documented evidence of non-compliance due to complex
polypharmacy.
4. The patient is prescribed four or more medications in addition to their
DMARD/Anti-TNF therapy.
On receipt of an acceptable referral form (found in appendix A), the clinic
coordinator will book an appointment and inform the patient when to attend.
On the day of the appointment the patient will present at the appropriate centre
and a rheumatology pharmacist will carry out a consultation which will be based
around one of the following areas.
1. A pre DMARD/Anti-TNF medication review and drug information session.
2. A consultation for patients with complex polypharmacy
After the consultation, the rheumatology pharmacist will record any
recommendations made and communicate these to the appropriate health care
professional. The rheumatology pharmacist will normally discharge the patient
from their care, but in cases where this is appropriate a follow up appointment
may be made through the clinic coordinator.
Referral to rheumatologist
If serious side effects occur or if the patient is suffering from acute flares that
warrant immediate treatment, after discussion with the rheumatology nurse
specialist, the rheumatology team looking after the patient may be contacted.
Where a reduction in dose or a temporary or permanent discontinuation of
DMARD/Anti-TNF is necessary, the rheumatology pharmacist will communicate
this to the patient. These interventions will only be made in accordance with the
product’s SmPC and will be communicated to the appropriate health care
professional taking responsibility for the patient’s drug therapy.
Failure to attend.
The clinic coordinator will document all DNAs.
Stewart E. Glaspole MRPharmS
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Supply of mediation.
The rheumatology pharmacist will not supply any medication without a signed
prescription. Patients are encouraged to obtain long-term supplies of their
medication from their GP where this is appropriate.
Stewart E. Glaspole MRPharmS
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Appendix A
Rheumatology pharmacist referral form
Please fill in as completely as possible and fax or send to the clinic coordinator.
Your role
RNS 
Consultant 
GP 
Your patient
Name _______________________
Hospital number if known____________
Address
Patients can only be seen by the rheumatology pharmacist if they satisfy
any TWO of the following criteria. Please tick all that apply.
1. The patient is 60 years old or over 
2. The patient has two or more co-morbidities in addition to the presenting
arthropathy 
3. There is documented evidence of non-compliance due to complex
polypharmacy 
4. The patient is prescribed four or more medications in addition to their
DMARD/Anti-TNF therapy 
Which type of consultation would you like the pharmacist to carry out?
1. A pre DMARD/Anti-TNF medication review and drug information session 
2. A consultation for patients with complex polypharmacy 
You will be sent a letter detailing any recommendations for your patient within
two weeks of the appointment.
Stewart E. Glaspole MRPharmS
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Appendix B Feedback communication
Rheumatology pharmacist clinic
Dear
Re Patient
I have today seen the above patient and have carried out the following
consultation.
A pre DMARD/Anti-TNF medication review and drug information session 
A consultation for patients with complex polypharmacy 
My recommendations for your patient are detailed below.
The patient is now discharged from my care/has been offered another
appointment to see me in _____ time.
With best wishes,
Rheumatology pharmacist
BSUH/BHCPCT
Stewart E. Glaspole MRPharmS
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Approved by
Ms. Jenny boncey
Pharmacy Services Manager,
BSUH NHS Trust
Date……….
PCT
Date……….
Rheumatologist
Date……….
Lead Rhem nurse specialist
Date……….
Stewart E. Glaspole MRPharmS
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