Methotrexate Support Tool
Methotrexate Support Tool
NHS Care Services
High Risk Medicine Initiative
Methotrexate Support Tool Notes - What is Methotrexate?
Methotrexate was first used to treat cancer. It is now know that low doses of the medicine can also help several joint, skin and bowel conditions. It is also used to treat some types of rheumatic disease.
What are the risks?
The NPSA in 2006 found that over ten years, 25 patients died in England and 26 suffered serious harm because they did not take their oral methotrexate correctly.
NPSA Guidance on Oral Methotrexate
The NPSA has sent out guidance on both safe prescribing and dispensing of methotrexate. The NPSA guidance relates to practice in England and Wales but many NHS Boards in Scotland will have reviewed their policies in light of the guidance. It may benefit individual contractors to ask their NHS Board for their local shared care protocol or consult the NHS Formulary for the location of the protocol.
NPSA Safe Prescribing Guidance
This information is for prescribers but is also useful for pharmacists to consider
| Methotrexate |
| Information on the risks and benefits of oral methotrexate should be given to the patient. Confirmation of the patient’s understanding and consent should be sought, baseline tests conducted, monitoring schedule explained, and patient-held monitoring booklet issued. |
| For NHS organisations with Shared Care Guidelines, the following issues should be addressed: clarity of prescribing and monitoring responsibilities; how often blood tests will be conducted and in which location; which clinician will be responsible for receipt and review of the results; who will communicate any necessary dosage changes to the patient and the GP; and who will record test results on the patient-held monitoring booklet. Drugs and Therapeutics Committees should refer to the section on managing risk within the Department of Health’s Medicines Management Framework. |
| NHS organisations without Shared Care Guidelines must make similar appropriate arrangements. The BSR has published guidelines on the monitoring of disease modifying drugs, including oral methotrexate, which may be a useful source of information. |
| All prescribers must avoid the use of ‘as directed’ in prescribing – a specific dose must be applied to each prescription. Bear in mind that patients often understand their dose by the number of tablets they take rather than ‘mg’. The required quantity and frequency of dose should be regularly discussed with the patient. Repeat prescriptions should be retained separately for prescriber review prior to authorising. It may help to change the printer driver software so that it shades the prescription signature space on FP10/WP10 to alert the prescriber to this high-risk drug. |
| Be aware of patients who attend with symptoms such as breathlessness, dry persistent cough, vomiting or diarrhoea, as these can be signs of oral methotrexate toxicity or intolerance. |
| Patients receiving oral methotrexate could be admitted to any ward or receive outpatient treatment for co-existing conditions. Staff in all areas may therefore be involved in ensuring continuity of prescribing, and monitoring or administering oral methotrexate. Full medication reviews, conducted where possible by pharmacists, should be undertaken on admission and prescribing, monitoring and administration requirements should be recorded in the patient’s notes. |
| It is the prescriber’s responsibility to record the correct dosage and frequency on the hospital drug administration chart, and to strike out the six days of the week when a dose must not be administered. |
| Handwritten prescriptions and discharge summary information must be complete, legible and include the form, strength, dose and directions in full |
NPSA Safe dispensing Practice Checklist
This information is useful for pharmacists to consider when designing their standard operating procedure for the supply of methotrexate.
| Methotrexate |
| Ask to see the patient’s monitoring booklet and check if any dose changes have been made since the last prescription issue. |
| Assess the needs of the individual patient. For example, if the new packaging is not available, patients who have reduced manual dexterity should be given larger containers or ribbed easy-to-grip lids as this could reduce the likelihood of them decanting the tablets into another container at home. |
| The strength of tablet supplied to the patient must stay consistent to prevent any confusion about the number of tablets they need to take, and the patient’s monitoring document and Patient Medication Record should be checked to confirm the previous supply. |
| Tell the patient their dose in terms of quantity of tablets and weekly frequency. Give the patient a monitoring booklet if they have not already got one. |
| Show the patient how to differentiate between the oral methotrexate and folic acid packaging. If they take both medicines at the same time, they will need to know how to distinguish between them, given that both may be round yellow tablets of similar size. |
| Be aware of patients who attend with symptoms such as breathlessness, dry persistent cough, vomiting or diarrhoea, as these can be signs of oral methotrexate toxicity or intolerance. You may need to refer them back to the prescriber. It is good practice to maintain a record of any over-the-counter items supplied to the patient. |
| Check the patient’s wristband against the medication administration record and the pharmacy labels attached to the medicine’s container. Check the patient’s name, the medicine, the strength of tablet, the dose and the timing. |
| Ask the patient to confirm that the medicine is required. This includes checking whether any new medications have been started since the last dose of methotrexate was administered. |
| Record the medication given on to the medication administration record at the time of administering it; a delay in recording it can result in one or more additional doses being given. |
Chronic Medication Service and Methotrexate risk assessment support tool
As part of CMS progression it has been agreed that support will be given in the first instance to two high risk medicines. One of these medicines is Methotrexate. To fulfil the requirements of the patient safety bulletin the following support tool has been integrated into PCR for completion with the patient.
Further information has been prepared by the Scottish Government to support pharmacists in delivering support to patients.
Community Pharmacy Scotland has sent every member in Scotland labels to support identification of completed dispensings for Methotrexate. This will make sure patients are easily identified for intervention when prescriptions are supplied to the patient.
An example of the Methotrexate label is below.
