18 October 2023

In this month’s blog, Dr Rosalind Benson (standing in as Digital Editor) spoke to Rebecca Heaton, rheumatology specialist pharmacist at Stockport Hospital and MDT Advisory Council member about her involvement in the use of biologics.

Can you talk me through some of the different roles you've had as a pharmacist relating to prescribing high-cost drugs?

Initially, I worked as an Independent Prescriber, helping with repeat prescribing. Over time, as I gained more experience and confidence, I became involved in initial drug prescribing. This involved more collaboration with consultants and nurses to assess patients for high-cost drug initiation, discussing different treatment options, drug types, monitoring requirements and cautions with the patient. I made treatment decisions in collaboration with the patient and consultant, taking responsibility for the initial prescription. I also conducted infusion clinics, ensuring patients were prepared for and received their infusions.

I became a specialist alongside my prescribing qualification, and this is a qualification others in their department have pursued as well, gaining confidence in their respective specialties before prescribing.

As part of the virtual high-cost drug clinic, do you discuss all patients' biologic drug choices, or do you handle straightforward decisions independently?

I don't discuss straightforward cases, such as first-time biologic prescriptions or clear switches, in the biologic MDT. Instead, I involve at least two professionals, the consultant who initiates the biologic and the pharmacist. They may challenge or agree with the choice, considering cost implications.

For more complex cases with treatment failures or comorbidities, face-to-face MDT meetings are held once a month. During these meetings, consultants present patients to a group consisting of pharmacists, nurses, consultants, and other members of the MDT. These meetings serve as valuable learning opportunities and provide advice to consultants regarding complex patient cases.

How long has your virtual biologics clinic been running?
Roughly two or three years, it was something I established as I recognised the need for broader expertise in drug choices and the potential benefits of involving consultants from different specialties. For example, it may be that one person knows more about connective tissue disease and they could bring that extra experience.

What are the main advantages that a pharmacist can bring to the team when making decisions about biologic high-cost drug choices?
We now have seven consultants with diverse specialties and patient cohorts. My position allows me to tap into a wealth of collective experience and knowledge. I can provide insights based on previous successful choices made by colleagues, supported by specialist advice, and share these lessons across our patient group. This levels the playing field in patient choice and also serves as an educational resource for our consultants, enhancing the overall decision-making process.

Do you think you bring experience from the use of high-cost drugs in different specialties like gastroenterology, for example, to then be able to have discussions in the meetings?
Yes, I maintain a strong network within our hospital, including high-cost drug pharmacists in gastroenterology, which enables me to seek advice and insights on specific drugs and their levels. Unlike doctors who often spend significant time on diagnoses, my role allows me to focus on treatment options and stay updated in this area, freeing them from that concern.

Additionally, I specialise in managing the cost aspect, which is vital given the evolving nature of high-cost drug prices and contracts. I work closely with pharmacy and finance to ensure we are aware of the most cost-effective options, providing medics with the necessary information to make informed decisions. This collaborative approach enhances the efficiency of our decision-making process.

You mentioned your involvement in biologic screening. How did this role come about, and what do you think, as a pharmacist, you're able to add to it?"

When I joined the department, I took on biologic screening to improve efficiency. Initially, consultants prescribed biologics directly to home care. I oversee the process as I see the need for a more structured approach. This ensures that patients are still responding to the treatment, reviewing clinic letters, confirming appointment attendance, and monitoring blood test results.

We also assess potential drug changes and dose reductions for long-term patients in remission due to the emergence of biosimilars. Our screening process involves a large patient volume, and we've optimised efficiency by utilising specialised technicians, not pharmacists, for prescription second checks, to ensure expertise is applied appropriately.

With changing guidelines, more patients are eligible for high-cost drugs. What changes have your team made to manage this increasing workload?
We've expanded our rheumatology pharmacy team to six members, including three pharmacists and three technicians, securing the necessary resources for effective management.

Any service developments that you are particularly proud of?
Traditionally, patients would wait weeks for appointments, but now, with streamlined procedures, they can start the treatment within two weeks of the decision in our department. The hospital's outpatient pharmacy provides counselling and teaches patients to self-administer, which of course, significantly reduces waiting times!

Check out our digital learning spotlight on biologics.

You can access podcasts on your usual provider by searching Talking Rheumatology spotlight.

You may be interested in the below spotlight on Biologics in rheumatology featuring Mariam Malik, and guest, Dr Chris Holroyd.