Last month, the research round-up provided you with an overview of articles looking at issues around opioid prescribing. This month, we will be looking at research published in the areas of rheumatology. The first article looks at the newly published update to the 2016 British Society for Rheumatology guidelines on prescribing antirheumatic drugs in pregnancy and breastfeeding. The second looks at prescribing in rheumatology with renal problems and, finally, we look at an article reviewing health literacy and the impact of this on medication management in the patient with rheumatoid arthritis.
British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: immunomodulatory anti-rheumatic drugs and corticosteroids
This article, published in the journal Rheumatology, looked at the newly published guidance by the British Society for Rheumatology. The article outlines the need for the guidance and discusses the rationale that led up to the update, including the existence of other evidence-based guidelines.
Within the objectives of the guidance, it outlines medications that should be avoided or stopped in pregnancy, or even in those of reproductive age unless contraception is used. The guideline target audience is all healthcare practitioners in the UK who are involved in managing patients with rheumatic diseases who are or are planning to become pregnant. It is acknowledged that chronic disease itself can have an impact on pregnancy, but that patients with rheumatological conditions can be safely managed during pregnancy, and how to avoid poor disease control while balancing the risks to the developing foetus. The guideline suggests preconception counselling where at all possible and referral to professionals with appropriate expertise is recommended. Risks and benefits of medications should be clearly discussed and documented, and pregnancy incompatible drugs replaced.
‘It is acknowledged that a person’s health literacy is a critical determinant of health, and has become an increasing focus in patient-centred care’
Other generic recommendations are clearly outlined to ensure full risk benefit analysis is performed and maternal safety is paramount. The article includes a tabulated summary of drug compatibility in pregnancy and breast milk exposure, which is a handy go-to guide for prescribers. This breaks down drug usage in preconception, first trimester, second and third trimester and breastfeeding as well as paternal exposure. The review suggests that awareness of these guidelines will aid clinical practitioners and patients in decision making. No barriers to implementation of these guidelines are anticipated by them and they outline key standards of care. The authors also link to an audit tool to assess compliance to the guideline.
Therapeutics in rheumatology and the kidney
This article in the journal Rheumatology is a review of evidence of prescribing in rheumatological conditions with regard to kidney safety. The authors begin by acknowledging that the field of rheumatology has advanced significantly in recent years and that, currently, the prescriber in this field has a wide array of prescribing possibilities, including numerous types of medications.
The previously heavily used drugs, such as non-steroidal anti-inflammatory drugs and the older disease modifying drugs, had known nephrotoxicity issues. It is known now, however, that the more modern disease modifying drugs show a considerable variation in their nephrotoxic potential. This can mean that, in some populations of patient; for example, those with chronic kidney disease where the older era drugs were precluded may now be able to assess a range of treatment options.
The review sets out clear aims and the mainstay is to provide the detailed evidence of the safety profiles, the efficacy rating and side effects of medications used in this field of practice. The focus will be specifically on treating rheumatological conditions in patients with chronic renal disease. The review looks at the traditional agents used, as well as the newer drugs and includes biologic and targeted synthetic drugs. Within the scope of this review, anti-gout prescribing in chronic renal disease is also covered. The aim of this is to move to providing practical guidance to prescribers in this area to promote patient safety, preserve disease management and avoid worsening of pre-existing renal conditions.
The impact of health literacy: associations with disease activity and medication prescription in patients with rheumatoid arthritis
This article, published in the clinical science section of the journal Rheumatology, looked at the impact of patients’ health literacy, its association with the progression of the disease and the use of medication in patients with rheumatoid arthritis. It is acknowledged that a person’s health literacy is a critical determinant of health, and has become an increasing focus in patient-centred care. This study expanded on previous research in the field of rheumatoid arthritis.
This single centre, retrospective cohort study conducted in the Netherlands between February and May 2019 involved 108 patients with rheumatoid arthritis receiving treatment at the centre. Participants had previously completed a health literacy questionnaire and up to 1 year of follow-up data was collected form patient health records held electronically. The categories of health literacy were assessed and participants assigned to ‘several health literacy limitations’, ‘some health literacy limitations’ or ‘good health literacy’. Demographic data was also collected. Appropriate statistical analysis was carried out in a longitudinal manner. The aim was to look for associations between the health literacy groups and disease activity over the studied year.
The results suggested that patients with good health literacy had significantly lower disease activity over time compared to the other groups, as measured by DAS28-ESR score, which comprised assessment of tender joints, swollen joints, ESR and patient indication of overall health. The results also revealed that patients with good health literacy were more likely to be prescribed biologic medication compared to the other groups who seemed to receive more traditional medications, including steroids. The authors report this is independent of age, gender, and formal education level.
The article concludes that health literacy does have an impact on disease activity and prescribing of medications, and the authors suggest initiatives such as health literacy assessment tools and the universal precaution approach could be implemented to help address the literacy divide. They add that better recognition of and attention to patients’ health literacy needs by health professionals is necessary for more optimal disease management and patient understanding.
Conclusion
Prescribing in the field of rheumatology is complex, with a range of medications available and the need to balance risk with benefit in many patient populations, such as pregnancy and breastfeeding and renal insufficiency. Patient understanding of disease can often be poor at diagnosis, but these chronic long-term conditions require patient education and involvement to aid the management of their conditions and maximise the drug benefit potential. The area of health literacy is an important one in all areas of clinical practice, but the research here relates to the specific need in this population.