Indication:Malignant disease, Chronic bowel disorders, Inflammatory bowel disease, Eczema & Psoriasis
Update NICE CG152
Crohn’s disease: management
Refer to NICE Guidance Crohns Disease CG152 October 2012
Safe Prescribing checklist
o Information on the risks and benefits of oral methotrexate should be given to the patient.
o Confirmation of the patient’s understanding and consent should be sought, baseline tests conducted, monitoring schedule explained, and patient-held monitoring booklet issued.
o All prescribers must avoid the use of âas directed’ in prescribing â 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 âmg’. The required quantity and frequency of dose should be regularly discussed with the patient.
o Repeat prescriptions should be retained separately for prescriber review prior to authorising.
o 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.
o Handwritten prescriptions and discharge summary information must be complete, legible and include the form, strength, dose and directions in full.
Safe dispensing practice checklist
o Ask to see the patient’s monitoring booklet and check if any dose changes have been made since the last prescription issue.
o 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 (Disability Discrimination Act applies).
o 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.
o 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.
o 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.
o 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.
NPSA Patient safety alert 13
Improving compliance with oral methotrexate guidelines 2006
Doctors, nurses, pharmacists and their staff must be made aware that the prescribing, dispensing and administering of oral
anti-cancer medicines should be carried out and monitored to the same standard as injected therapy. This requires that:
* Healthcare organisations should prepare local policies and procedures that describe the safe use of these oral
* Treatment should be initiated by a cancer specialist.
* All oral anti-cancer medicines should be prescribed only in the context of a written protocol and treatment plan.
* Non-specialists who prescribe or administer on-going oral anti-cancer medication should have ready access to
appropriate written protocols and treatment plans including guidance on monitoring and treatment of toxicity.
* Staff dispensing oral anti-cancer medicines should be able to confirm that the prescribed dose is appropriate for the
patient, and that the patient is aware of the required monitoring arrangements, by having access to information in the
written protocol and treatment plan from the hospital where treatment is initiated and advice from a pharmacist with
experience in cancer treatment in that hospital.
* Patients should be fully informed and receive verbal and up-to-date written information about their oral anticancer
therapy from the initiating hospital. This information should include contact details for specialist advice, which can be
shared with non-specialist practitioners. Written information, including details of the intended oral anti-cancer regimen,
treatment plan and arrangements for monitoring, taken from the original protocol should be given to the patient. When
shared with pharmacists and dispensing staff, this would enable the above dispensing requirements to be satisfied.
* Full use should also be made of NHS cancer centre web sites to provide information for healthcare staff, patients and carers to ensure the safe use of oral anti-cancer medicines.
Risks of incorrect dosing of oral anti-cancer medicines – NPSA January 2008