Doncaster & Bassetlaw Area Prescribing Committee October 2009 V2.0

Shared Care Proforma for the Management of Inflammatory Arthritis

& Connective Tissue Disease for Adult services, over 16

To be completed by Specialist

PATIENT DETAILS: (please complete or attach sticky label)
Name:

Date of birth:

NHS No:

Address:
/ PATIENT’S GP:
CONSULTANT DETAILS:
Name (PRINT) Trust

Signature Date

DRUG, DOSAGE AND ROUTE

Name of Drug:

Dosage:

Route:
The Shared Care Protocol V 2.0 is available on the Medicines Management Webpage:
http://medicinesmanagement.doncasterpct.nhs.uk / Date of initiation
by Consultant:

Date when dosage in stabilised (usually, but not exceptionally, after a period of 3 months)

MONITORING ARRANGEMENTS (to be completed by consultant)

Hospital / Specialist
·  Baseline monitoring of (tick if appropriate)
ð FBC ð WBC ð Platelets ð Urinalysis
ð U&Es ð LFTs ð Urinalysis for Proteinuria & Blood
ð Differential WBC ð Creatinine
ð TPMT ð BP ð Chest X-Ray
·  Continued monitoring (tick if appropriate)
ð 4-Weekly FBC ð 4-Weekly Urinalysis
ð FBC, WBC & Urinalysis before each injection
ð Fortnightly FBC, U&E & Urinalysis for first 3
Months then every 4 weeks
ð 2-Weekly FBC, WBC & LFT for first 12 weeks, then
Every 3 months for first year then 6-Monthly
thereafter (or 1 month after dose increase)
ð Weekly FBC & LFTs for first 6 weeks then monthly
ð 6-Monthly U&Es
ð Fortnightly ð FBC ð LFT ð U&E for 6 weeks
After any dose increase
ð Monthly FBC, Differential WBC, LFT & BP for
First 6 months then every 8 weeks
ð Fortnightly FBC, WBC, U&Es & LFTs for first
6 weeks then monthly thereafter
ð Ask patient about respiratory symptoms
/
GP / Practice
·  Ongoing monitoring
o  Side effects
o  Symptom Control
·  Specialist GP Lead Monitoring
o  Monthly FBC & LFTs
o  6-Monthly U&Es
o  Ask about respiratory symptoms at monitoring

OTHER MEDICATION

/

RESPONSIBILITY / ACTION IN CASE OF PROBLEMS
Contact: Office Hours – Specialist
Telephone DRI Rheumatology Tel 01302 553281
Out of hours – On-call DRI Tel: 01302 366666
.

To be completed by GP and returned to specialist

I agree to this shared care proposal and am willing to prescribe from

(Start date)

GP name (printed) GP signature Date

NB: Please call Specialist if further information or support is required prior to signing.

ROUTINE MONITORING TO BE CONDUCTED UNDER SHARED CARE ARRANGEMENTS

DRUG / CONSULTANT / GP

Auranofin (Oral Gold)

/ ·  Baseline: FBC,WBC,Platelets,Urinalysis, U&Es, LFTs & Urinalysis for proteinuria and blood
·  Routine:
4-Weekly FBC & Urinalysis / ·  Side Effects
·  Symptom Control
Sodium Aurothiomalate (Injectable Gold) / ·  Baseline:
FBC, WBC, Urinalysis, U&Es, LFT, Urinalysis for proteinuria and blood
·  Routine (before each injection):
FBC, WBC & Urinalysis (when stable for 8 weeks it is permissible to work one week in arrears for FBC) / ·  Side Effects
·  Symptom Control
Penicillamine / ·  Baseline:
FBC, differential WBC, U&Es, Creatinine & Urinalysis for proteinuria and blood
·  Routine:
2-Weekly FBC, U&E & Urinalysis for first 3 months then every 4 weeks / ·  Side Effects
·  Symptom Control
Sulfasalazine / ·  Baseline:
FBC, WBC, Creatinine, LFT
·  Routine:
2-Weekly FBC, WBC & LFT for first 12 weeks, then 3-Monthly for first year then 6-Monthly thereafter (or 1 month after dose increase) / ·  Side Effects
·  Symptom Control
Azathiprine / ·  Baseline:
FBC, LFT, U&Es & TPMT
·  Routine:
Weekly FBC & LFTs for first 6 weeks then monthly (FBC & LFT fortnightly for 6 weeks after any dose increase)
6-Monthly U&Es / ·  Side Effects
·  Symptom Control
Leflunomide / ·  Baseline:
LFTs, U&Es, Creatinine, BP, FBC, Differential WBC
·  Routine:
Monthly FBC, Differential WBC, LFT
& BP for first 6 months then every 8
weeks / ·  Side Effects
·  Symptom Control
Methotrexate / ·  Baseline:
U&Es, Creatinine, LFTs, FBC, Differential WBC, Platelets and Chest X-ray
·  Routine:
Fortnightly FBC, WBC, U&Es & LFTs
for first 6 weeks then monthly
thereafter (fortnightly for 6 weeks
after any dose increase) / ·  Side Effects
·  Symptom Control
Doncaster PCT Local Enhanced Service
·  Monthly FBC & LFTs
·  6-Monthly U&Es
·  Ask about respiratory symptoms at monitoring

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This document will be reviewed in light of new or emerging evidence or by April 2014