1. Methotrexate in Psoriasis Shared Care Guidelines
Principles of shared care
Content of the shared care guidelines
How and where to access the shared care guidelines
Oral methotrexate is a safe and effective medication if taken at the right dose and with appropriate monitoring
However, there are potential serious side effects to treatment.
E.Y. Cheung
Medicines Management Team
Camden CCG
19th May 2016

2. National Patient Safety Agency (NPSA) Alert
Oral methotrexate associated with high rate of adverse incidents and deaths
Due to prescribing, dispensing, administering or monitoring errors
Recommended actions:
Patient information & hand-held booklet
Shared Care Guidelines
Avoid ‘as directed’ – state dose
Separate repeat Px for review before signing
NPSA alert highlighted that oral MTX is associated with a high rate of adverse events and reports of death. It was found that these were due to a range of issues including prescribing, monitoring, dispensing and administration errors.
The alert was issued to all NHS organisations and recommended checklist of measures that should be taken to prevent such incidents occuring to ensure the safe use of oral MTX.
Safe prescribing practice – recommended action includes:
providing information to the patient on the risks and benefits of MTX treatment, explaining the monitoring schedule and issuing a patient-held monitoring booklet
Recommends shared care guidelines to provide clarity on the prescribing and monitoring responsibilities, monitoring arrangements and communication of results and dose changes
Advice– not to use ‘as directed’ - state the dose and bear in mind that patients understand their dose by number of tablets rather than ‘mg’
Ensure there is a system in place to separate repeat prescriptions to review before signing or authorising repeat prescriptions
These measures have been incorporated into clinical practice now.
Working with the people of Camden to achieve the best health for all

3. Principles of Shared Care
Defines the individual responsibilities of the consultant/specialist team, GP and patient
Information to enable GP to take on the legal and clinical responsibility of prescribing
Communication between specialist, GP and patient
GPs are invited to participate.
Patient – explanation, consultation and agreement
Clarify responsibilities of the specialist, GP and patient so it is absolutely clear what each party should be doing in the shared care agreement.
Framework that provides sufficient clinical information to enable the GP to make an informed decision regarding taking on the legal and clinical responsibility of prescribing
Shared care assumes communication between the parties (specialist, GP and patient). The SCG should clearly state the communication lines and responsibilities. Patients should not be used as conduits for communication between the specialist and the GP
Shared care is a request and there is no obligation to take on shared care if the GP is not confident to undertake the role. If unable to take on shared care, notify specialist within 14 days with the reason. Medication cost should not be a reason to refuse shared care.
The intention to share care should be explained to the patient by the specialist when treatment is initiated. It is important that the patient is consulted about the treatment and are in agreement with it and understand their responsibilities
Working with the people of Camden to achieve the best health for all

4. Content of Shared Care Guidelines
Criteria – psoriasis patient is initiated in secondary care and stablised on methotrexate, baseline assessments and monitoring after initiation
Roles and responsibilities of specialist, GP and patient
[who prescribes, who monitors, frequency of blood tests and in which location, who is responsible for receipt and review of results, who will communication dose changes to patients and GP, who will record test results in the patient-held monitoring booklet, attending appts]
Clinical information ie indication, dose, administration, cautions, adverse effects, monitoring requirements, drug interactions, use in pregnancy and lactation. What action to take in the event of abnormal results.
Contact details for specialist team
NCL wide MTX SCG currently being developed and updated
Criteria – patients who are stabilized on MTX and have been monitored appropriately at baseline and after initiation of treatment with no problems identified during this period.
Roles and responsibilities – these are clearly defined and detailed in the guidelines
Who will prescribe
Who will monitor
Test required, why they are needed, frequency of testing, location of tests and actions to be taken for any abnormal results
Which clinician will be responsible for receipt and review of results
Who will communicate any necessary changes in dose to the patient and GP
Who will record test results in the Patient held Monitoring and Dosage Record booklet
Clinical information – important for sufficient information for GP to take on the safe prescribing and monitoring
Contact details for specialist team – important in the event that specialist advice needs to be sought
NCL wide SCG – all NCL CCG MTX SCG currently being reviewed and a joint NCL SCG being developed by the NCL JFC Shared Care Group – due to be finalised in June

5. Medicines Management Webpage
The shared care document can be accessed via two portals
Camden CCG Staff Intranet webpae
Select Teams and then Medicines Management to take you through to the Medicines Management webpage and there is a section on Shared Care
Working with the people of Camden to achieve the best health for all

6. Medicines Management Webpage
Via GP Website
The second portal is from the GP website page. Scroll down to medicines management and select and click through to the Medicines Management webpage
If there is time, then mention the MTX LCS which practices can sign up to deliver.
Working with the people of Camden to achieve the best health for all

7. Working with the people of Camden to achieve the best health for all
Key Points
Patient education/counselling and patient-held monitoring booklet
Ensure you clear on the responsibilities and are happy to these on
Prescribe 2.5mg tablets only (not 10mg tablets)
Weekly dosing frequency
Avoid the use of ‘as directed’ – state the dose
Recall and call system (patients missing monitoring appts)
Camden CCG Locally Commissioned Service (LCS) for prescribing and monitoring methotrexate
Working with the people of Camden to achieve the best health for all

8. Working with the people of Camden to achieve the best health for all
Thank you and any questions?
Working with the people of Camden to achieve the best health for all