Evolution of Clinical Pharmacy in the Practice of Rheumatology

Abstract

P harmacists are valuable members of multidisciplinary teams caring for patients with rheumatic diseases, serving as clinicians, educators, and researchers. As pharmacotherapy specialists, pharmacists are essential in providing evidence-based clinical care and drug information and serving as patient care advocates to ensure safe and cost-effective drug therapy.The need for clinical pharmacy services in the practice of rheumatology has expanded over the past 40 years and continues to evolve as new therapeutic targets are identified and novel technologies and pharmacologic approaches become available. Prior to this time, nonsteroidal antiinflammatory drugs (NSAIDs), colchicine, antimalarial drugs, corticosteroids, penicillamine, and sulfasalazine were available for clinical use. 1-3 In 1971, Nobel Prize winner John R Vane demonstrated that the mechanism of acetylsalicylic acid effects was inhibition of cyclooxygenase (COX)-mediated production of prostaglandins and thromboxanes. This research subsequently led to the development of additional NSAIDs, including selective COX-2 inhibitors, 4 with wide variability in therapeutic 5 and toxic 6 responses associated with these agents. However, since NSAIDs provided only symptomatic relief, there was a need for the use of disease-modifying antirheumatic drugs (DMARDs) that could affect the progression of disabling diseases such as rheumatoid arthritis.By 1987, the effectiveness of methotrexate in the management of rheumatoid arthritis was so impressive that the Health and Public Policy Committee of the American College of Physicians developed guidelines for its use prior to Food and Drug Administration (FDA) approval for this indication. 7 Oral gold, azathioprine, cyclosporine, cyclophosphamide, leflunomide, mycophenolate, and biological response modifiers (tumor necrosis factor [TNF] blockers, and interleukin-1 [IL-1] receptor antagonists) were also being used to manage an array of rheumatologic conditions during the 1980s into the 21st century. 1,8 During that time, it was recognized that combination therapy with several of those DMARDs achieved an additive or synergistic response, 9 and that early and aggressive intervention in patients with newly diagnosed rheumatoid arthritis could slow radiographic progression of joint damage, limit disability, increase the likelihood of remission, and decrease mortality. 10-12 Most recently, a recombinant form of urate oxidase (rasburicase) 13,14 and agents that inhibit T-cell activation (abatacept)12 or deplete B lymphocytes (rituximab) 12 are being used in rheumatology.As we look toward the future, new biologic therapies that deplete or inhibit the activation of other inflammatory cells, proinflammatory/regulatory cytokines, chemokineinduced migration of inflammatory cells into the synovi-

Multidisciplinary members’ perspectives on a pharmacist joining a rheumatology practice team

“…Such pharmacist care is becoming established among rheumatology clinics in a number of other countries. 6-9 While pharmacists have assumed medication management roles in both inpatient and outpatient hospital care settings, there is not yet a proliferation of pharmacists in specialty primary care practices in Canada. Nearly 75% of the nation’s pharmacists work in commercial community settings.…”