I had to sign a shared care agreement to get the next batch of methotrexate, anyone know what it is?

[Cally55]

Methotrexate shared care GP not happy to prescribe without it

[HeronNS]

Shared care between your specialist and your GP?

[Cally55 in reply to HeronNS]

Yes, but what is the implication? Specialist said methotrexate safe and well toerated, GP says its a dangerous drug that he is not really qualified to deal with. Told by pharmacy that these agreements only apply to about 5 meds. Took 8 weeks and a lot of agitation to get hospital to send the paperwork, repeat prescription organised with 1 day to spare!

[PMRpro Ambassador]

Your GP sounds a bit precious. I think you need to speak to both the rheumatologist and the GP about this. I suspect that the GP only knows of mtx used as chemotherapy - which is far far higher doses and can be a rather nasty experience. It has been used in rheumatology for many years now and is probably the most commonly used drug in rheumatoid disease.

rheumatoidarthritis.net/tre...

This

pharmrev.aspetjournals.org/...

says "As currently used, low-dose methotrexate is safe and well tolerated. Because of its efficacy and safety, low-dose methotrexate is now first-line therapy for the treatment of rheumatoid arthritis not responsive to nonsteroidal anti-inflammatory drugs alone (American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines, 2002)."

So heaven only knows what your GP is talking about! You must be monitored with regular blood tests - but that applies to many drugs. What is the implication? If it were me I'd find a different GP! One who knows a bit more or is willing to check before upsetting his patient. The only thing I might disagree with is "well tolerated" - for many patients it IS well tolerated but about a third of patients discontinue it because of side effects that are unaccceptable to them. It seems to be one thing or the other, little halfway house.

And it won't matter if you don't get the mtx in time - if you develop an infection you should have been told to miss the dose so your body has a better chance of getting over it.

[Cally55 in reply to PMRpro]

Thanks, I think there is some kind of turf war between the GPs, the hospital and the CCG, the hospital has lost several referrals and the GPs have to deal with me moaning! My sympatheties are with the GPs who are always helpful and sympathetic. I think they did the first repeat without the paperwork but were unwilling to continue!

I would like to know why I have to sign this thing, is it so that I have no comeback if things go pearshaped?

Hopefully nothing will go wtong and it is safe and well tolerated!

[PMRpro Ambassador in reply to Cally55]

Ask them. But there will almost certainly be a turf war - the GPs will want the hospital budget to pay for your medication and the hospital will not. Though 25 mtx tablets costs the enormous amount of 4.99 euros here - and it won't be much different in the UK.

[Hidden]

Drugs have prescribing Categories, Red, Amber, Green.

Red ~ only prescribed & issued by Consultants

Amber ~ prescribed by Consultants but prescriptions can be issued by GP Surgery

Green ~ GP can prescribe

Methotrexate is Amber, my Consultant prescribed it & GP continued to issue it.

My Methotrexate had to be stopped for Surgery & when l was ready to restart it, my Consultant has to issue the first script & GP continued after that.

For Info

When l had Chemo there were some Meds l had that had to initiated by a Consultant & then GP could write the Scripts.

[Hidden in reply to Hidden]

I had never heard this... good to know. Thanks.

[Andymurph]

Here's an example of a shared care agreement with regard to Methotrexate. They are quite common in UK Health trusts where GP's and specialists share patient care.

Specialist responsibilities

1 Perform initial assessment of patient prior to initiation of methotrexate, including baseline monitoring of renal function, liver function and full blood count (FBC), and a baseline chest X-Ray if the patient has not had a previous normal chest X-Ray in the last 12 months.

2 Ensure that female patients are not pregnant. Explain to both male and female patients the importance of not conceiving during and for six months after treatment with methotrexate.

3 Initiate treatment and prescribe at least the first month supply of medication.

4 Issue patient with a methotrexate monitoring booklet and explain that only 2.5mg tablets will be issued.

5 Discuss the benefits and side effects of treatment with the patient and emphasise the importance of regular

monitoring and the importance of reporting any signs or symptoms of infection promptly.

6 Ask the GP whether he or she is willing to participate in shared care, and discuss the shared care arrangement

with the patient & obtain their consent.

7 Ensure compatibility of methotrexate with other concomitant medication.

8 Supply GP with summary within 14 days of a hospital out-patient review or in-patient stay.

9 Review the patient's condition and monitor response to treatment at least annually or as deemed clinically

necessary.

10 Give advice to the GP concerning ongoing prescribing, monitoring, dosage adjustments and when to stop

treatment.

11 Report adverse events to the MHRA & GP.

12 Ensure clear backup arrangements exist for GPs to obtain additional advice and support should they need it.

General Practitioner responsibilities

1 Reply to the request for shared care as soon as practicable.

2 Prescribe medicine at the dose and frequency recommended by the specialist.

3 Undertake monitoring as per monitoring schedule on page 4.

4 Ensure compatibility of methotrexate with other concomitant medication.

5 Refer promptly to specialist when any loss of clinical efficacy is suspected (e.g. worsening of disease-related

symptoms, new symptoms suggestive of disease recurrence or progression) or intolerance to therapy occurs.

6 Report to and seek advice from the specialist on any aspect of patient care that is of concern to the GP and

may affect treatment.

7 Stop treatment on the advice of the specialist.

8 Report adverse events to the specialist and MHRA.

Patient's role

1 Attend all appointments with GP and specialist. Including appointments for blood tests and other monitoring.

2 Report to the specialist or GP if he or she does not have a clear understanding of the treatment.

3 Report any signs or symptoms of infection to the specialist or GP promptly.

4 Share any concerns in relation to treatment with medicine.

5 Inform specialist or GP of any other medication being taken, including over-the-counter products.

6 Report any adverse effects to the specialist or GP whilst taking the medicine.

7 Patients should keep alcohol consumption within well defined limits (do not exceed 21 units per week for men

and 14 units per week for women and have at least one alcohol free day each week)

[Cally55]

Thank you, now I know!

All the specialist did was send me for a chest x-Ray and give me a prescription to take to the pharmacy. GPs seem to have done their bit, without the paperwork.

It probably doesn't matter but I would have liked a bit more explanation at the outset!

[PMRpro Ambassador in reply to Cally55]

Patients are supposed to see a rheumy specialist nurse and have it all explained to them - including all the risks and downsides.

[JamieRN]

Methotrexate is now black boxed in the US. The dangers of getting cancer far out weigh the benefits. I stopped taking it when the form was presented to me

[PMRpro Ambassador in reply to JamieRN]

That's interesting Jamie. I shall read that with interest - do you know when it was issued?

I was at a scientific meeting a couple of weeks ago and had a long conversation with an immunologist who basically said something similar. She thinks it is safer to use a bit more pred than to add in additional immunosuppressants like mtx and azo etc. I have always had that gut feeling but no evidence before.

[Hidden in reply to JamieRN]

What do you mean by black boxed Jamie?

[PMRpro Ambassador in reply to Hidden]

"A black box warning is the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration (FDA) when there is reasonable evidence of an association of a serious hazard with the drug."

en.wikipedia.org/wiki/Boxed...

[Hidden in reply to PMRpro]

There we go! Who can read or understand the small print! All about trust as usual.