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Practice Nurse

Therapeutic Monitoring

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The aim of therapeutic drug monitoring (TDM) is to optimise drug therapy concentrations to manage a patient’s medication regime and improve their conditions. Sub optimal treatment has been shown to result in poor patient outcomes.1 While they may not be actively involved in monitoring decisions, practice nurses need to understand their role and responsibilities for patients requiring therapeutic monitoring.2

The following MCQs will look at five common areas where therapeutic monitoring will be required.

This resource is offered at intermediate level and includes five assessment questions to support your continuing professional development. Complete the resource, including the further reading and some or all of the suggested activities, to obtain a certificate for one hour of continuing professional development to include in your annual portfolio.

After completing this module you will be able to:

Appreciate the importance of good communication and liaison with patients so that blood tests are timely and appropriate

Understand the rationale for disease modifying anti-rheumatic drugs (DMARDs)

Understand the process for diagnosing iron deficiency anaemia

Appreciate the importance of monitoring patients on lithium therapy

Understand the importance of ensuring a patient’s understanding of their treatment regime for hypothyroidism.

1. Jones, M., et al. Evaluation of the pattern of treatment, level of anticoagulation control, and outcome of treatment with warfarin in patients with non-valvular atrial fibrillation: a record linkage study in a large British population. Heart 2005:91(4):472-477. 

2. Nursing and Midwifery Council. The Code: Professional standards of practice and behaviour for nurses and midwives, 2015 

http://www.rcgp.org.uk/membership/practice-team-resources/~/media/1E0765D171B44849876EA38FC97E96F1.ashx

A 54 year old woman receiving warfarin therapy fails to attend for her booked appointment for International Normalised Ratio (INR) testing. You notice on her records that she is in full time employment.

A systematic call and recall service should be in place with appropriate strategies and processes for occasions where patients fail to attend their appointments. A new appointment should be scheduled as soon as possible – ideally within one week – taking into account clinical criteria. Where a patient fails to attend a further time for an INR test, the GP should be informed and he or she may decide that it is unsafe to continue issuing prescriptions for therapy until the patient has attended and her INR has been tested. This is why it is important that all communications should be entered on the patient records: simply mentioning to a colleague that the patient failed to attend for the appointment could well mean she slips through the safety net and is lost to follow up. Specimens should NEVER be stored in the vaccine refrigerator, nor is it appropriate to store blood specimens for a length of time (for example overnight). This will have a detrimental effect on the specimen and the accuracy of the result. This should be explained to the patient so that she understands why she may need to take time out of her working day for the INR test. It is also wise to ensure that the patient has been fully informed about anticoagulant therapy, and understands your explanations. NHS Choices publishes a useful summary for patients on warfarin.1

1. NHS Choices. Anticoagulants, warfarin – Interactions. 

http://www.nhs.uk/Conditions/Anticoagulants-warfarin-/Pages/Interactions---other-medicines.aspx

Novel oral anticoagulants: where they fit in clinical practice

Speak to one of your patients on warfarin therapy and find out how they find it impacts on their life. Do they understand about contra-indications and the side effects to look out for?

Question 1

A 48-year-old woman comes to see you at the surgery. She has been recently diagnosed with rheumatoid arthritis. She has been prescribed methotrexate, sulphasalazine and hydroxychloroquine. Arrangements have been made for regular blood monitoring but she admits to feeling a little overwhelmed when she was told about her diagnosis and treatment was instigated, and asks you to explain why she needs regular blood tests.

The drugs that this lady has been prescribed are known as disease modifying anti-rheumatic drugs (DMARDs). They have proved a major advance in the management of rheumatoid arthritis (RA). They improve outcomes by suppressing the immune response and controlling inflammation.1-2

Following diagnosis of RA, NICE recommends that all patients should be commenced on three DMARDs (methotrexate, sulphasalazine and hydroxychloroquine) with monthly reviews to monitor their effect. The dosage is increased over a three-month period to reduce inflammation. If a patient does not respond to DMARD therapy and the RA remains active then biologic therapy should be commenced. If the individual patient does not respond to the first biologic agent or it is not tolerated, an alternative should be offered.3

An individual prescribed DMARDs will require regular blood tests to assess for bone marrow suppression, liver and renal dysfunction as well as the effectiveness of the treatment.

It is important to establish that the patient understands the pros and cons of DMARD treatment and that they understand their options. It is not appropriate to expect someone to do just do as they are instructed, nor does just giving the patient a leaflet mean that they will understand the information. Emphasising the dangers of DMARDs without discussing the benefits may just frighten the patient into refusing treatment. Failing to address the patient’s concerns at the time they are raised could well mean that the patient does not pursue this further, and so may not go on to discuss this with the doctor on another occasion.

1. Visser K, van der Heijde D. Optimal dosage and route of administration of methotrexate in rheumatoid arthritis: a systematic review of the literature. Annuals Rheumatic Disease 2009: 68:1094-1099

2. Doan T, Massarotti E. Rheumatoid arthritis: an overview of new and emerging therapies. Journal of Clinical Pharmacology 2005: 45:751-62

3. NICE CG79. Rheumatoid arthritis: the management of rheumatoid arthritis in adults, (updated) 2013. 

Rheumatoid Arthritis, diagnosis and management

http://pathways.nice.org.uk/pathways/rheumatoid-arthritis

Identify a patient with RA who is taking DMARD therapy. Ask them to talk about living with RA, and the impact (positives and any negatives) that DMARDs have had on their condition.

Question 2

A 27-year-old woman had attended your surgery during the previous week looking pale and complaining of feeling tired all the time. A blood test was taken to assess her full blood count. Today, she telephones you asking for the result. The full blood count indicates that the patient has a low haemoglobin level. Which of the following statements is true?

A low haemoglobin level should not be dismissed, but neither can conclusions be drawn from a low haemoglobin result on its own: further tests should be carried out, together with detailed history from the patient regarding diet and any significant blood loss. Other factors which can cause a low haemoglobin would include faulty synthesis of haemoglobin, reduced erythropoiesis and excessive haemolysis (destruction of arythrocytes).1 If a diagnosis of iron deficiency is reached after further testing, a diet rich in iron will support improvement but additional treatment will be based upon identifying and addressing the underlying cause.

1. Phillips J, Murray P and Kirk P. The Biology of Disease. Blackwell Science; Oxford: 2001

Reflect on how you would describe iron deficiency anaemia to a patient. Check your understanding by looking at the patient information leaflet on this condition at Patient.co.uk

http://www.patient.co.uk/health/iron-deficiency-anaemia-leaflet

Question 3

A patient who is on lithium therapy attends infrequently and you suspect non-compliance. He presents with symptoms that may indicate toxicity. He gives a history of self-medicating according to his mood. Do you?

Individual patients will vary in their susceptibility to toxicity,1 This is why it is important to look for signs and symptoms which may indicate toxicity. Lithium is known to cause gastrointestinal effects such as anorexia, nausea and diarrhoea, together with Central Nervous System effects such as muscle weakness, drowsiness, ataxia, course tremor and muscle twitching. If there is a previous history or a suspicion of non compliance and you arrange for the patient to return for a blood test with accurate record of their last dose, or suggest they book an appointment with the GP to discuss their treatment, there is every likelihood that they will not attend. Simply telling the patient that they need to take their medication as prescribed does not necessarily mean that they will take your advice. Taking a blood sample – with the patient’s consent – while he or she is present is advisable, in order to confirm or rule out toxicity, so that timely and appropriate action may be taken. For this reason, it is also important to enter on the laboratory request form that there is a suspicion of toxicity.

Lifestyle assessment and advice is an important part of the annual review for this patient, but not a solution in itself for addressing compliance and suspected toxicity. The charity Rethink Mental Illness, in association with the Royal College of Nursing, Royal College of General Practitioners and Royal College of Psychiatrists, has developed an integrated physical health pathway, which sets out the for primary role and responsibilities for monitoring the physical health of patients with mental health conditions.2

1. Taylor D, Oaton C, Kapur S (Eds). The Maudsley Prescribing Guidelines in Psychiatry 11th Edition Oxford; Wiley-Blackwell: 2012

2. Rethink Mental Illness. Integrated physical health pathway, 2014. 

http://www.rcpsych.ac.uk/pdf/NAS%20Integrated%20Physical%20Health%20Pathway%20Dec%2012.pdf

Managing long term mental health conditions in primary care

Run a search of your practice records to establish how many patients are on lithium therapy. Have any of them presented with toxicity? How was this actioned and addressed?

Question 4

A 71-year-old patient was diagnosed a few months ago with hypothyroidism. She was commenced on levothyroxine 25mcgs once daily before breakfast. She returned after eight weeks for a repeat thyroid function test and her results had improved significantly. She also reported feeling much better in herself when she attended for the blood test. However, since then she has not attended surgery, and has not ordered any repeat prescriptions.

Which of the following is the correct way forward?

Levothyroxine treatment usually has to carry on for life with thyroid function being checked every 12 months. It is important that the patient is fully informed, understands and is involved in their treatment plan.1

This will avoid any misconceptions or misunderstandings. While practice nurses may not be responsible for medication review and dose titrations, if they become aware of a patient who is lost to follow up, or has other reasons to suspect non-compliance, then it would be their responsibility to alert accordingly.2

While it is important to give patients the information they require, it is of equal importance to establish they understand the information that has been given.3

1. Franklyn J. Prescribing thyroid hormones. Prescribers’ Journal 1996;36(1):9-13.

3. Elwyn G, Edwards A, Wensing M, et al. Shared decision making: developing the OPTION scale for measuring patient involvement. Qual Saf Health Care 2003;12(2): 93–9. 

http://qualitysafety.bmj.com/content/12/2/93.long

Spend some time studying the NICE Clinical Knowledge Summary on Hypothyroidism. Reflect on how this might help you to explain the importance of ongoing therapy to your patients.

Therapeutic Monitoring

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