Evaluation of a pharmacist-led virtual thiopurine clinic

摘要

Introduction: Monitoring of patients on immunomodulator therapy for inflammatory bowel disease (IBD) and auto-immune hepatitis (AIH) significantly increases clinical workload in gastroenterology outpatient clinics owing to blood test monitoring requirements. Aim: This study conducted at Barnsley Hospital NHS Foundation Trust aimed to determine the clinical impact of a pharmacist-led virtual thiopurine clinic on drug monitoring, safety and quality of service in a cohort of IBD and AIH patients. Method: Patients attended an initial face-to-face outpatient consultation and were then followed-up via remote telephone consultations, as part of a virtual clinic, at two-week intervals. Patient biochemical data were analysed alongside anonymous postal questionnaires to provide an assessment of the quality of the service over a three-month period between 1 May and 31 July 2014. A second survey was performed in December 2019 to re-assess patient satisfaction. Results: 81 patients were assessed; clinical indications for thiopurines were IBD (n=75) and AIH (n=6). Overall, 39.5% (n=32) patients failed to reach the thiopurine therapeutic target (2mg/kg with normal thiopurine methyltransferase) owing to drug intolerance, lack of clinical response or hepatotoxicity. Thioguanine nucleotide analysis was performed in 29.6% (n=24) of patients who failed initial treatment, to allow dose optimisation. Hepatotoxicity developed in 9.9% (n=8) of patients, which required shunting of thiopurine metabolism with allopurinol. Myelosuppression developed in 6.9% (n=21) of the total number of blood tests performed (n=304), leading to discontinuation of thiopurines in two patients. The questionnaire response rate was 51.9% (n=42); 92.9% of respondents (n=39) found the virtual clinic to be convenient, and 95.2% (n=40) were satisfied with the service. The follow-up survey included 373 patients with a 35.9% response rate (n=134); 88% (n=118) found the service easily or very easily accessible, and 82% (n=109) found it very helpful or extremely helpful. Overall satisfaction was highly rated (average 4.46/5). Conclusion: Pharmacist-led virtual thiopurine clinics were shown to be safe and regarded favourably by patients. The clinics identified patients exposed to the risks of myelosuppression, as well as allowing thiopurine dose optimisation during the three-month period from May to July 2014. The follow-up survey in 2019 showed patients valued telemedicine as an alternative to face-to-face visits. Virtual clinics offer a viable alternative to traditional outpatient-driven thiopurine monitoring, especially during the ongoing COVID-19 pandemic.