The use of DMARDs, with methotrexate as the backbone of the treatment, has revolutionised RA management, but there is still room to maximise the benefit. Rheumatologists, GPs, nurses, pharmacists and other allied health professionals can each play a role in improving coordinated care for RA patients. This can help to initiate treatment earlier, keep patients on optimal treatment, and enable regular monitoring to maintain the prolonged benefit of disease-modifying treatment.
Home News Shared care approaches to rheumatoid arthritis: supporting early and sustained methotrexate A A. Shared care approaches to rheumatoid arthritis: supporting early and sustained methotrexate Rheumatoid arthritis treatment has been revolutionised by the use of DMARDs like methotrexate. Key points Methotrexate is the gold standard for rheumatoid arthritis RA treatment. It can reduce symptoms, limit disease progression and bring RA into clinical remission. Urgent referral to a rheumatologist, and early diagnosis and treatment initiation is essential. Consistent messaging from all healthcare professionals can address patient concerns about methotrexate.
Structured collaboration between patients, GPs, rheumatologists and other healthcare professionals can support an earlier start to treatment, better adherence and better outcomes. In the majority of RA patients, adverse effects can be managed. As low-dose methotrexate has evidence for preventing joint damage and improving quality of life, adherence should be optimised. Download and print MedicineWise News: Shared care approaches to rheumatoid arthritis: supporting early and sustained methotrexate Date published : 18 May Download PDF.
Low-dose methotrexate for RA Conventional synthetic disease-modifying antirheumatic drugs csDMARDs are the cornerstone of RA treatment, and can minimise or prevent joint damage and induce clinical remission in RA patients.
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Features suggesting rheumatoid arthritis These include. Drug toxicity monitoring : Regular monitoring for DMARD adverse effects is needed, including appropriate kidney and liver tests and full blood count. Monitoring is most frequent in the first 3 to 6 months of therapy, and after dose increases when adverse effects are most likely.
Most vaccines can be given safely. Disease activity review : Initial reviews should be performed every 1—3 months for patients with high disease activity.
Clinical assessments can be less frequent, such as every 6 months, once the treatment target has been stabilised. Complications : Monitor and manage potential complications including atherosclerosis, osteoporosis, depression, vasculitis, lung disease and neuropathy. Systemic inflammation is the main contributor to the increased risk of developing atherosclerosis for patients with RA, however other risk factors for cardiovascular disease should be actively managed.
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Prescribing pointers for methotrexate GPs can prescribe methotrexate and play an important role ensuring its safe and effective use. Always specify which day of the week it should be taken eg, Monday. Serious toxicity can occur if taken more frequently.
Think carefully about the number of tablets and repeats you prescribe to reduce the risk of incorrect dosing. Use folic acid to decrease the risk of adverse effects including gastrointestinal adverse effects, liver transaminitis and mouth ulcers.
Shared care Protocols
The dose should be at least 5 mg a week. Folic acid should not be taken on the same day as the weekly methotrexate dose. Consider administering methotrexate subcutaneously to reduce gastrointestinal adverse effects and increase bioavailability.
Consider splitting the weekly dose into two doses, administered 12 hours apart, if adverse effects occur. References Rheumatology Expert Group. Therapeutic Guidelines: Rheumatoid arthritis. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: update. Ann Rheum Diseases ; Managing the drug treatment of rheumatoid arthritis. Aust Prescr ; Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying antirheumatic drugs for rheumatoid arthritis: abridged Cochrane systematic review and network meta-analysis.
BMJ ;i Ann Rheum Dis ; Arthritis Rheumatol ; Treating rheumatoid arthritis to target: update of the recommendations of an international task force. Rheumatoid arthritis. Lancet ; Diagnosis and early management of inflammatory arthritis. BMJ ;j Tight control in the treatment of rheumatoid arthritis: efficacy and feasibility. Ann Rheum Dis ;66 Suppl 3:iii The value of referral letter information in predicting inflammatory arthritis--factors important for effective triaging.
Clin Rheumatol ; General practitioners' referral letters--Do they meet the expectations of gastroenterologists and rheumatologists? To improve the quality of rheumatology care, we created shared care between rheumatologist and family physician to reduce hospital visits. A case manager coordinated the workflow. Patients without hospital subsidies private patients and private family physicians independently predicted successful shared care, defined as one cycle of alternating care.
Health care affordability impacts successful shared care. Government subsidy hindered right siting to private primary care. Structural integration will create a seamless continuum between hospital and primary care. Musculoskeletal disorders rank highest in prevalence as the causes of chronic ill health, long-term disabilities and consultation with health professionals, and rank second for restricted activity days and use of prescription and non-prescription drugs [ 1 — 3 ]. Singapore's rapidly ageing population and changing disease profiles call for urgent implementation of community-based chronic disease care delivery to provide comprehensive, accessible, affordable, quality care [ 5 ].
The management of musculoskeletal problems relies heavily on referral to tertiary care in the Singapore health care system. These include self-limiting problems such as soft tissue complaints, chronic conditions such as gout and osteoarthritis, which require an initial consultation for diagnosis and management plan and return to primary care. Patients with musculoskeletal diseases which include inflammatory arthritis, however, require close monitoring and frequent hospital appointments.
Laboratory monitoring for toxicities associated with immunosuppressant therapy mandates regular hospital review as there is no defined primary care physician for each individual in Singapore. Singapore has 48 rheumatologists; the majority provides care within the public sector, serving a population of 5. Limited and delayed access to the rheumatologist hinders the provision of appropriate and timely care for patients with rheumatic diseases [ 7 ]. Median waiting time for a rheumatology appointment in Singapore public hospitals is 45 days.
Information for professionals
Singapore's health care system is dual, public and private. Unlike the British National Health Service, where residents are entitled to health care that is mostly free at the point of consumption, the Singapore government promotes personal responsibility for one's health and the avoidance of over-reliance on state welfare or medical insurance. Singapore's health care financing system is based on patient's cost-sharing or co-payment either through cash or Medisave, a mandatory medical savings programme and a low cost medical insurance scheme Medishield.
A Standard Drug List provides a wide range of essential drugs at affordable prices in public institutions. Inpatient subsidies are even more substantial. However, patients are free to choose between public or private providers; for the latter, no government concessions are available. In the absence of supplementary private insurance plans, out of pocket costs are higher for those who choose private care.
Private care is available also in public hospitals although their primary mission is to serve the disproportionately larger pool of subsidized class patients. Singapore's total population was last recorded at 5.
Shared Care Guidelines | West Hampshire CCG Website
Exponential population growth over the past five years strained infrastructure and public services, prompting a surge in the need for new health care infrastructure and health care professionals. The epidemiological transition of the major causes of deaths from communicable to non-communicable diseases together with changing demographics with falling birth rates crude birth rate per 1, residents in was The challenge to manage chronic disease is heightened by the disparity of generalists delivering primary care in the public sector.
Rising patient loads at specialist outpatient clinics in public hospitals, where traditionally patients with chronic diseases are cared for, make it an urgent priority.
Our primary objective was to improve the quality of rheumatology care by creating shared care between the rheumatologist and family physician to reduce the burden of hospital care. Our secondary objective was to actively discharge patients. Both objectives therefore fulfilled the goal of right siting. The concept of shared care was introduced to pilot a new model of care. Improving family physician skills, assigning appropriate patients to family physicians and coordinating care between family physicians and rheumatologists were used to achieve the objective.
Shared care refers to care of patients where treatment is initiated in the specialist setting but, at an agreed time, prescribing and drug monitoring is shared with primary care. The rheumatologist's responsibility is to request a sharing of care and provide written guidance on the arrangements for sharing of care between the family physician and hospital specialist. We used clinical practice improvement methodology to look at how to increase patient numbers participating in shared care or being discharged [ 11 ]. Of the patients surveyed, only 12 3.