Which drugs need monitoring?
Common monitoring requirements
This list isn’t complete, instead showing the most common drug monitoring requirements
Drug | FBC | Renal | Liver | Other | Intervals |
Methotrexate, Azathioprine, Sulfasalazine, Leflunomide, Mercaptopurine, Mycophenolate, Ciclosporin | Neutrophil, WCC, Platelets, MCV & Lymphocytes | eGFR | ALT | 3 Months | |
Rivaroxaban, Apixaban, Edoxaban, Dabigatran | ANNUAL: Neutrophil, WCC, Platelets, MCV & Lymphocytes | Creatinine (Serum) | ANNUAL: ALT | Actual body weight & calculate creatinine clearance | 6 Months |
ADHD Medications | Actual body weight, HR and BP | 6 Months | |||
Antipsychotics (Quetiapine, Aripiprazole, Risperidone, Olanzapine) | Neutrophil, WCC, Platelets, MCV & Lymphocytes | Creatinine (Serum), eGFR + U&Es | ALT | HbA1c, Lipids, Prolactin
HR, BP & BMI | 12 Months |
Lithium (also see Lithium Management) | Renal profile (eGFR + U&Es) | Lithium levels, Bone profile, Thyroid
BMI | 1 Week after dose change, and then 3 Months | ||
Sodium Valproate | Neutrophil, WCC, Platelets, MCV & Lymphocytes | eGFR | ALT | 6 Months, then Annual |
SPS: Drug Monitoring
The Specialist Pharmacy Service provide a list of tests for initiating, stabilizing, and ongoing monitoring
- There are 5 tabs, each with its own timeframe - press the three lines menu next to ‘Before starting’
- The first 4 lists should be checked for the specific medications - ‘Abnormal results’ is currently empty
- Clicking on a medication name provides detailed instructions, including information for specific indications
Shared-care agreements
See also Shared Care Agreements
- Patients aren’t usually discharged, and they will continue to see their specialist
- It should only happen with patient consent, and when their condition is stable & predictable
- The agreement should explicitly state what is expected from us, and at what intervals
- Common drugs include methotrexate, azathioprine, hydroxychloroquine, ADHD medications, and Freestyle Libre sensors for type 2 diabetes
Monitoring process
Blood & other tests
- Request bloods on TQuest, and advise the patient to collect the form from reception. See Common Appointment Requests for advice on in-house & external phlebotomy.
- Patients can come into reception to take blood pressure (See also Blood Pressure Readings)
- Patients can submit their weight, or use scales in the waiting area for BMI
Good monitoring practices
- If we access hospital records for blood test results, these must be transferred to our records in EMIS
- If a medication will need monitoring in less than 3 months, it should only be issued until the date for monitoring. The monitoring should be arranged to give enough time for the results to arrive.
- If a patient would run out of medication before results are available, we should continue to prescribe
Audits
It is best practice and encouraged that all Practice Pharmacists perform routine, practice-wide audits.
- An audit is conducted to review a set of pre-decided criteria, to ensure we are safely monitoring medication, and practicing and prescribing in-line with national guidelines
- Criteria will be decided annually by the lead pharmacist, and discussed in Pharmacy Team Meetings
- For example, an audit could review patients on Lithium to ensure appropriate monitoring is being conducted, or review patients on NSAIDs with high risk of GI bleed to ensure they are co-prescribed a PPI
Background & expectations
GMC Guidance
Good practice in prescribing and managing medicines and devices, states that prescribers should be assured that medicines remain safe and necessary for the individual.
This still applies when shared care arrangements are in place, and the legal responsibility to ensure safety rests with the person signing the prescription.
Our Responsibility
Patients who are prescribed high-risk or regularly monitored medicines should be monitored in line with all of the following, where available:
- Practice protocol, which reflects national guidance
- Shared care agreement specific to the patient
- Manufacturer’s summary of product characteristics (SPC) for the product
If we do not arrange blood tests ourselves, we must see the results or a letter stating monitoring remains satisfactory before issuing a prescription.
This also applies if we are issuing prescriptions while monitoring is managed in secondary care.