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MMI Scenario 4


You are working within a busy GP practice and have been tasked by the on-call GP to undertake a discharge medication review from a patient under the care of Rheumatology who has been previously receiving Methotrexate 15mg weekly at your local hospital. Last bloods (FBC,CRP, ESR, U+Es, LFTs) were normal four weeks ago and the specialist team wishes for the care to be discharged back into primary care. What further issues do you wish to explore before inviting the patient in for a discharge review and potentially issuing this medicine? What would support you and the practice in the safe transfer of care for this patient?

Example Answer


Documentation: Before calling this patient in for a review, it is important to ensure we have received the appropriate documentation/letters/clinical summaries which support in the ongoing care and monitoring of this patient. 

High risk drug prescribing: Methotrexate (MTX) is a high risk medicine, a Disease modifying anti-rheumatic drug (DMARD), it will be under ‘shared care arrangements’ in particular before we agree to accept prescribing/monitoring responsibility, a GP must have read and signed a shared care agreement form with evidence of upload and recent bloods being available within the given patients care record.

Drug Monitoring: The interval of methotrexate monitoring must be stipulated within the shared care guidelines, along with recent blood tests and ongoing monitoring requirements, conditions of areas of responsibility for the GP, clinician and patient. 

Clinical Safety: As the clinical letter just stipulated methotrexate 15mg tablets weekly, it is important the patient recognizes this will be issued as 2.5mg tablets, so prescriptions will be written as 6 on a given day each week. For prescription safety this should be written as ‘Take SIX tablets (total weekly dose 15mg) WEEKLY’. In words to avoid error. The discharge summary did not mention about folic acid 5mg tablets. Again, this is important in reducing MTX associated side effects, e.g. stomatitis, mucosal symptoms. The patient should be counselled on ensuring they take folic acid on a different day to the day of MTX. The exact dosage should be confirmed with the consultant prior to issuing or verified with the patient on calling to ensure safe and effective medicines reconciliation. 

Patient informed: The patient should be aware of the drug monitoring practice protocol and given information on how blood tests will be done, where and the process of requesting/organizing his repeat medicine. They should also be informed prescriptions will not be issued before a blood test is undertaken and the requesting clinician will review the results before issuing any MTX.

Patient counselling: The patient should also be counselled on when/how to report side effects e.g. sore throat, fever, malaise, systemic upset and given an early appointment in the event of any neutropenia and when to be referred to specialist. They also should be counselled on the safe and effective OTC/herbal remedies, e.g. avoidance of NSAIDs owing to reduced MTX elimination and potential toxicity. Patient should be aware of sign of toxicity, e.g. neutropenia, bruising, bleeding, sore throat etc.