When we think of the health professionals that make up an MS team, neurologists and MS nurses are often the first that spring to mind. A role that’s perhaps not so much at the forefront of an MS service, but is still vital, is that of the MS pharmacist.
MS pharmacists have expertise in the prescribing and dispensing of MS medications, as well as ongoing monitoring, managing side effects, advising on interactions and ensuring newly available drugs are ready to be prescribed.
We spoke to two MS pharmacists, Brina and Aoife, to find out more about their role within an MS service and to hear the latest developments on drugs in the pipeline.
What is the role of a pharmacist within an MS team?
Aoife says: Our role as MS pharmacists is quite varied – we have patient-facing and non-patient facing roles. Our typical day involves screening, checking prescriptions and running a monitoring clinic, where we oversee blood monitoring for people on disease modifying drugs (DMDs) for those who require extra monitoring. With the MS nurses, we run DMD education and screening clinics, where we talk through the medication that a person is about to begin. We also provide an MS medicines information service to doctors, nurses, and people with MS.
The non-patient facing role involves contributing to service development and improvement. For example, we will contribute to audits and clinical guidelines which are discussed at our clinical governance meetings. We also work with our colleagues across London and nationally, for example, contributing to NICE guidelines. We also network with other pharmacists to share good practice and discuss challenges to try and improve the care provided to people with MS.
Can people with MS talk to you directly?
Brina says: Pharmacists working in a hospital role are often in the background, providing a supporting role to the nurses and doctors. Unfortunately, sometimes we don't get to meet all of our patients face to face in a traditional clinic setting. However, we are in contact with people with MS on a daily basis, and available to speak to them if they need us.
Usually our contact is related to DMDs. It may also be related to blood monitoring or interactions with other medications or dietary supplements. We provide advice on symptomatic medications as well, not just to people with MS but to GPs too if they have any queries.
We commonly receive questions around vaccines. For instance, if someone's going travelling, whether the vaccines they need are safe for them to take. We also answer queries regarding contraception or if medication is safe in pregnancy and breastfeeding.
What work do you have to do behind the scenes when a new drug gets approved for use on the NHS?
Aoife says: When a new drug is approved for use on the NHS, we must inform our Use of Medicines Committee that we are intending to use it at our NHS Trust. The drug is added to our formulary (a list of approved drugs that may be prescribed at our Trust) to be used in line with national guidance. If the medication is a new DMD, usually a new pathway and a clinical guideline will be agreed by our MS service.
We must ensure that we have resource to support the prescribing, administration, delivery and long-term monitoring thereafter. We also need to give an indication of how many people are likely to need the drug, and whether it will replace existing treatment or if it is a new line of treatment. We must make sure that there is funding available for that treatment.
We also communicate and collaborate with our peers, locally and nationally, to share how they're delivering the same service so that we can agree and share good practice, but also discuss how we get around different challenges. MS treatment is a rapidly evolving landscape. We are always thinking months and years ahead, so that we are aware of what's coming next and so that we can try to plan in advance.
Can you talk through some of the DMDs that are in the pipeline, or starting to become available, for relapsing remitting MS (RRMS)?
Brina says: In terms of medications coming through in the pipeline, we have Kesimpta (ofatumumab) for RRMS which is an under-the-skin injection that can be administered at home after the first dose. This will be a convenient home-based, high efficacy medication, especially if people with MS don't want to come into hospital for their treatment.
Tysabri (natalizumab) is a high efficacy option now available as an under-the-skin injection. Currently it is given as an infusion into a vein over one hour. The frequency of administration will still be the same. It will still need to be given in a medical setting, but it will speed up the time spent in hospital as it won't need to be given as an infusion over one hour and observation time can be reduced if the treatment is tolerated.
On the horizon, there's ponesimod which is undergoing NICE consultation for RRMS. There's also diroximel fumarate which has just been submitted to the EMA for licensing. The trials have shown that it has fewer gastrointestinal side effects than Tecfidera (dimethyl fumarate) which can sometimes cause stomach upset, constipation and diarrhoea when people first start it.
An interview with two MS pharmacists
In this video, we speak to MS pharmacists, Brina and Aoife, to find out about their role within an MS service, how they support people with MS and the latest developments on drugs in the pipeline.
What does the landscape look like for people with progressive MS in terms of treatments?
Brina says: More research is happening in progressive and advanced MS now. We're optimistic that new treatments, or repurposed drugs, will become available for this group of people. There are a number of studies currently ongoing.
- ChariotMS trial – looking at whether Mavenclad (cladribine) can slow down the worsening of hand and arm function in people with advanced MS.
- Oratorio-Hand trial – examining the effect of Ocrevus (ocrelizumab) on upper limb disability progression.
- MS-STAT2 trial – investigating whether simvastatin can slow down progression in MS by protecting the nerves from damage.
We’re watching these trials closely to see if they have positive results.
How can you support people with progressive MS who aren't on a DMD, but are using a range of symptomatic treatments?
Aoife says: This is an area that we are keen to develop. Up until now, people with progressive MS have predominantly received community-based care, and therefore any interaction with a specialist MS pharmacist would be more reactive, for example, if they're admitted to hospital for an ailment. However, as more treatment options become available which require specialist input and monitoring, for example DMDs and symptomatic medication, we are meeting and learning more about this group of people.
Our potential here is to proactively decrease preventable harm, mainly caused by problematic polypharmacy – so being on too many medications. As pharmacists, we can perform medication reviews which involves going through all the medication someone may be on and assessing whether they're working, and if they're having any adverse effects that are causing them to feel unwell. We can look at all of their medications and ensure that they're getting the best from each one and, if necessary, switch or stop the medications that aren't working or are causing unpleasant side effects. Our priority is to make sure that people get the right medication at the right time.
Can you provide some clarity on whether people with MS have to pay prescription charges for their medications?
Brina says: Having MS is not a prescription payment exemption, although if someone is exempt for other reasons they would not need to pay, eg because of their age or other medical conditions.
All medications that are delivered by home delivery, eg home care companies such as Healthcare at Home or Lloyds Pharmacy, don’t need to be paid for. If a medication is administered during a hospital admission, for example, a Tysabri infusion, it wouldn’t need to be paid for. This is the same for medication which is given to go home with if it’s linked to a hospital admission. For example, people that come in for Lemtrada (alemtuzumab) treatment may take home antibiotics or antivirals – they don't need to pay for those.
However, if a medication is dispensed using an outpatient prescription, for example after a clinic visit or if they collect their medication from the hospital pharmacy, then they will be charged an NHS prescription fee.
People can always discuss prescription charges with their pharmacist to see if there's a better way we can provide the medication for them. The majority of our medications are provided by home delivery as, for most people, it’s more convenient.
Brina Bharkhada is an MS specialist pharmacist at the National Hospital for Neurology and Neurosurgery, Queen’s Square, London. Aoife Shields is also based at the National Hospital and is the principal MS pharmacist.
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