Common use of xx/xxx Clause in Contracts

xx/xxx. Duration of Treatment Long term Dermatology patients: 6 moths to 1 year in majority of patients Responsibilities of the specialist initiating treatment General:  To assess the suitability of the patient for treatment.  To ensure that the patient/carer has received counselling and understands the therapy, its benefits, limitations, continued monitoring (where applicable), adverse effects.  Inform the GP of the information provided to the patient.  To review the patient as agreed intervals and copy all relevant results to the GP  Carry out disease and drug monitoring as listed below  Formally hand over to GP by letter and patient informed Prescribing:  Initiate treatment with ciclosporin. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it has been initiated. Disease & drug monitoring:  Monitor bloods according to schedule:  Discuss shared care arrangement with patient.  Support and advise GPs as required.  Assess response to treatment and initiate any dose changes as clinically appropriate including discontinuation of treatment. Blood pressure Baseline In Rheumatic and connective tissue disease Serum creatinine needs to be measured at least twice before commencing treatment. In cutaneous disease A dermatological and physical examination including blood pressure and renal function required before starting. Urinalysis FBC U+Es LFTS Urate and lipids 24 hour urine creatinine clearance Blood pressure Then every 2 weeks until stable dose reached for more than 6 weeks and no change in NSAID therapy (RA patients). U+Es FBC LFTS Lipids After the first 2-3 months of treatment. Responsibilities of the General Practitioner General and Prescribing:  Monitor and prescribe as recommended by the specialist. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it has been initiated or when the patient is on a stable dose.  Vaccinations – note annual influenza vaccine and single dose pneumococcal vaccine should be offered unless otherwise advised by the specialist.  If patients are exposed to chickenpox or shingles, passive immunisation should be carried out using varicella zoster immunoglobulin. Please contact consultant microbiologist for further advice or refer to the green book (chapter 34).  Notify specialist if treatment with ciclosporin is discontinued or if unable to take on shared care..  Ensure there are no drug interactions with any other medications initiated in primary care.  Prescribe by brand Disease & drug monitoring:  Carry out drug monitoring as listed – and communicate abnormal results to the specialist.  Ensure the correct brand of ciclosporin is prescribed as stated by the prescriber.  Urgent drug discontinuation/ referral to specialist as clinically appropriate  To stop treatment on the advice of the specialist.  To refer back to the specialist if the patient’s condition deteriorates.  To identify adverse effects if the patient presents with any signs and liaise with the hospital specialist where necessary. To report adverse effects to the specialist and where appropriate to the Commission on Human Medicines/MHRA (Yellow Card scheme). Unless otherwise stated by the secondary care specialist, apply the following monitoring frequencies following handover from secondary care: Discontinue ciclosporin and seek advice from initiating team if: Neutrophils <1.6x 109/L AST or ALT >3 times upper limit of normal Blood pressure Monthly for 4 months then every 3 months. On dose increase – at week 2,4, 8 and then every 3 months as above. U+Es FBC LFTs Lipids Every 3 months. If no change at 6 months stop monitoring routinely At consultations Ask about oral ulceration, unexplained bruising/ bleeding, rash, sore throat. Platelets <140 x109/L Blood pressure >160/95 or risen >20mmHg (despite the addition of standard antihypertensive therapy. Potassium >5.5mmol/l Creatinine clearance Rises by >30% of baseline on 2 consecutive occasions one week apart. Lipids Significant rise Tremor/ gingivalhyperplasia/ hirsutism/ confusion Responsibilities of the Patient / Carer: General :  Report any possible side effects to their GP, in particular potential signs and symptoms of bone marrow suppression (e.g. unexplained bruising, bleeding, sore throat, infection etc.)  Practice safe exposure to the sun  Ensure they have adequate supply of medication.  Attend appointments including those for drug monitoring.  Discuss options if considering pregnancy with GP/specialist  To notify the Dr issuing prescriptions (hospital or GP) if wishing to start any new medication purchased over the counter (including herbal remedies) Communication Specialist to GP:  The specialist will inform the GP when they have initiated ciclosporin and when there are any subsequent changes in treatment.  Inform the GP of the information provided to the patient  Ensure that brand of ciclosporin has been communicated with GP GP to Specialist:  To inform specialist if not able to take on the monitoring and prescribing  Irrespective of whether prescribing responsibility has been accepted or not, inform the consultant of relevant medical information regarding the patient and changes to the patient’s medication regime irrespective of indication.  Notify specialist if treatment with ciclosporin discontinued. Specialist Contacts Department of Rheumatology – 01423 553389 Department of Dermatology – 01423 553740

xx/xxx. Duration of Treatment Long term Dermatology patients: 6 moths to 1 year in majority of patients Responsibilities of the specialist initiating treatment General:  To assess the suitability of the patient for treatment.  To ensure that the patient/carer has received counselling and understands the therapy, its benefits, limitations, continued monitoring (where applicable), adverse effects.  Inform the GP of the information provided to the patient.  To review the patient as agreed intervals and copy all relevant results to the GP  Carry out disease and drug monitoring as listed below  Formally hand over to GP by letter and patient informed Prescribing:  Initiate treatment with ciclosporin. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it it. has been initiated. Disease & drug monitoring:  Monitor bloods according to schedule:  Discuss shared care arrangement with patient.  Support and advise GPs as required.  Assess response to treatment and initiate any dose changes as clinically appropriate including discontinuation of treatment. Responsibilities of the General General and Prescribing:  Monitor and prescribe as recommended by the specialist. The Blood pressure Baseline In Rheumatic and connective tissue disease Serum creatinine needs to be measured at least twice before commencing treatment. In cutaneous disease A dermatological and physical examination including blood pressure and renal function required before starting. Urinalysis FBC U+Es LFTS Urate and lipids 24 hour urine creatinine clearance Blood pressure Then every 2 weeks until stable dose reached for more than 6 weeks and no change in NSAID therapy (RA patients). U+Es FBC LFTS Lipids After the first 2-3 months month of treatment. Responsibilities of the General Practitioner General and Prescribing:  Monitor and prescribe as recommended by the specialist. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it has been initiated or when the patient is on a stable dose.  Vaccinations – note annual influenza vaccine and single dose pneumococcal vaccine should be offered unless otherwise advised by the specialist.  If patients are exposed to chickenpox or shingles, passive immunisation should be carried out using varicella zoster immunoglobulin. Please contact consultant microbiologist for further advice or refer to the green book (chapter 34).  Notify specialist if treatment with ciclosporin is discontinued or if unable to take on shared care..  Ensure there are no drug interactions with any other medications initiated in primary care.  Prescribe by brand Disease & drug monitoring:  Carry out drug monitoring as listed – and communicate abnormal results to the specialist.  Ensure the correct brand of ciclosporin is prescribed as stated by the prescriber.  Urgent drug discontinuation/ referral to specialist as clinically appropriate  To stop treatment on the advice of the specialist.  To refer back to the specialist if the patient’s condition deteriorates.  To identify adverse effects if the patient presents with any signs and liaise with the hospital specialist where necessary. To report adverse effects to the specialist and where appropriate to the Commission on Human Medicines/MHRA (Yellow Card scheme). Unless otherwise stated by the secondary care specialist, apply the following monitoring frequencies following handover from secondary care: Discontinue ciclosporin and seek advice from initiating team if: WCC <3.5x109 /L Neutrophils <1.6x 2 x 109/L AST or ALT >3 times upper limit of normal Platelets <140 x109/L Blood pressure Monthly for 4 months then every 3 months. On dose increase – at week 2,4, 8 and then every 3 months as above. U+Es FBC LFTs Lipids Every 3 months. If no change at 6 months stop monitoring routinely At consultations Ask about oral ulceration, unexplained bruising/ bleeding, rash, sore throat. Platelets <140 x109/L Blood pressure >160/95 or risen >20mmHg (despite the addition of standard antihypertensive therapy. Potassium >5.5mmol/l Creatinine clearance Rises by >30% of baseline on 2 consecutive occasions one week apart. Lipids Significant rise Tremor/ gingivalhyperplasia/ hirsutism/ confusion Responsibilities of the Patient / Carer: General :  Report any possible side effects to their GP, in particular potential signs and symptoms of bone marrow suppression (e.g. unexplained bruising, bleeding, sore throat, infection etc.)  Practice safe exposure to the sun  Ensure they have adequate supply of medication.  Attend appointments including those for drug monitoring.  Discuss options if considering pregnancy with GP/specialist  To notify the Dr issuing prescriptions (hospital or GP) if wishing to start any new medication purchased over the counter (including herbal remedies) Communication Specialist to GP:  The specialist will inform the GP when they have initiated ciclosporin and when there are any subsequent changes in treatment.  Inform the GP of the information provided to the patient  Ensure that brand of ciclosporin has been communicated with GP GP to Specialist:  To inform specialist if not able to take on the monitoring and prescribing  Irrespective of whether prescribing responsibility has been accepted or not, inform the consultant of relevant medical information regarding the patient and changes to the patient’s medication regime irrespective of indication.  Notify specialist if treatment with ciclosporin discontinued. Specialist Contacts Department of Rheumatology Prescribing specialist to be contacted via Hospital switchboard on 01423 885959 Medicines Information – 01423 553389 Department of Dermatology – 01423 553740553084

xx/xxx. Duration of Treatment Long term Dermatology patients: Time to response is normally between 6 moths to 1 year in majority of patients weeks and 3 months but is likely dependent on indication. Treatment can be lifelong. Responsibilities of the specialist initiating treatment General:  • To assess the suitability of the patient for treatment.  • To ensure that the patient/carer has received counselling and understands the therapy, its benefits, limitations, continued monitoring (where applicable), adverse effects.  • Exclude pregnancy before starting treatment and advise patient to use contraception during therapy and for 6 weeks after stopping. • Inform the GP of the information provided to the patient.  • To review the patient as agreed intervals and copy all relevant results to the GP  • Carry out disease and drug monitoring as listed below  • Formally hand over to GP by letter and patient informed Prescribing:  • Initiate treatment with ciclosporinMycophenolate. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately .Mycophenolate. Approximately 2 months after it has been initiated. Disease & drug monitoring:  • Monitor bloods according to schedule:  • Discuss shared care arrangement with patient.  • Consider pregnancy test if appropriate. • Support and advise advice GPs as required.  • Assess response to treatment and initiate any dose changes as clinically appropriate including discontinuation of treatment. Blood pressure Baseline In Rheumatic and connective tissue disease Serum creatinine needs to be measured at least twice before commencing treatment. In cutaneous disease A dermatological and physical examination including blood pressure and renal function required before starting. Urinalysis FBC U+Es LFTS Urate and lipids 24 hour urine creatinine clearance Blood pressure Then every 2 weeks until stable dose reached for more than 6 weeks and no change in NSAID therapy (RA patients). U+Es FBC LFTS Lipids After the first 2-3 months of treatment. Responsibilities of the General Practitioner General and Prescribing:  • Monitor and prescribe as recommended by the specialist. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin Mycophenolate approximately 2 months after it has been initiated. • Notify Consultant if treatment with Mycophenolate is discontinued or if unable to take on shared care • Ensure there are no drug interactions with any other Medications initiated or when the patient in primary care. Test Baseline Frequency Hepatitis B and C HIV Consider Varicella immune status √ (avoid if recurrent herpes/shingles0 BP, CrCL, √ FBC/ U+E/ LFT/ √ two weekly until on stable dose for 6 weeks then monthly for 3 months, then 3 monthly thereafter • Annual flu vaccination is on a stable doserecommended.  Vaccinations – note annual influenza vaccine and single dose pneumococcal vaccine should be offered unless otherwise advised by the specialist.  If patients are exposed to chickenpox or shingles, passive immunisation should be carried out using varicella zoster immunoglobulin. Please contact consultant microbiologist for further advice or refer to the green book (chapter 34).  Notify specialist if treatment with ciclosporin is discontinued or if unable to take on shared care..  Ensure there are no drug interactions with any other medications initiated in primary care.  Prescribe by brand Disease & drug monitoring:  • Carry out drug monitoring as listed – and communicate abnormal results to the specialistSpecialist.  Ensure the correct brand of ciclosporin is prescribed as stated by the prescriber.  • Urgent drug discontinuation/ referral to specialist as clinically appropriate  • To stop treatment on the advice of the specialist.  • To refer back to the specialist Specialist if the patient’s condition deteriorates.  • To identify adverse effects if the patient presents with any signs and liaise with the hospital specialist Specialist where necessary. • To report adverse effects to the specialist Specialist and where appropriate to the Commission on Human Medicines/MHRA (Yellow Card scheme). • Consider bronchiectasis or pulmonary fibrosis if patients develop persistent respiratory symptoms. Unless otherwise stated by the secondary care specialistSpecialist, apply the following monitoring frequencies following handover from secondary care: Test Frequency FBC/U+E/LFT Monthly for 3months then every 12 weeks Dose increases chould be monitored by FBC and LFTs at 2 and 6 weeks and then as above. Discontinue ciclosporin mycophenolate and seek advice from initiating team if: Neutrophils <1.6x 1.6 x 109/L AST or ALT >3 times upper limit of normal Blood pressure Monthly for 4 months then every 3 months. On dose increase – at week 2,4, 8 and then every 3 months as above. U+Es FBC LFTs Lipids Every 3 months. If no change at 6 months stop monitoring routinely At consultations Ask about oral ulceration, unexplained bruising/ bleeding, rash, sore throat. Platelets <140 x109/L Blood pressure >160/95 Patients should be warned to report immediately any signs or risen >20mmHg (despite the addition of standard antihypertensive therapy. Potassium >5.5mmol/l Creatinine clearance Rises by >30% of baseline on 2 consecutive occasions one week apart. Lipids Significant rise Tremor/ gingivalhyperplasia/ hirsutism/ confusion Responsibilities of the Patient / Carer: General :  Report any possible side effects to their GP, in particular potential signs and symptoms of bone marrow suppression (e.g. unexplained bruising, infection or bruising or bleeding, sore throat, infection etc.)  Practice safe exposure to the sun  Ensure they have adequate supply of medication.  Attend appointments including those for drug monitoring.  Discuss options if considering pregnancy with GP/specialist  To notify the Dr issuing prescriptions (hospital or GP) if wishing to start any new medication purchased over the counter (including herbal remedies) Communication Specialist to GP:  • The specialist will inform the GP when they have initiated ciclosporin Mycophenolate and when there are any subsequent changes in treatmenttreatment – standard clinic letter.  • Send a copy (either electronically or paper copy) of the Shared Care Guideline to the GP and ask whether they are willing to participate in shared care. • Inform the GP of the information provided to the patient  Ensure that brand of ciclosporin has been communicated with GP patient. GP to Specialist:  To inform specialist if not able to take on the monitoring and prescribing  • Irrespective of whether you accept prescribing responsibility has been accepted or not, you should inform the consultant of relevant medical information regarding the patient and changes to the patient’s medication regime irrespective of indication.  • Notify specialist Consultant if treatment with ciclosporin Mycophenolate is discontinued. Specialist Contacts Department of Rheumatology – Prescribing Consultant to be contacted via Hospital switchboard on 01423 553389 Department of Dermatology – 01423 553740885959

xx/xxx. Duration of Treatment Long term Dermatology patients: 6 moths to 1 year in majority of patients Responsibilities of the specialist initiating treatment General:  • To assess the suitability of the patient for treatment.  • To ensure that the patient/carer has received counselling and understands the therapy, its benefits, limitations, continued monitoring (where applicable), adverse effects.  • Inform the GP of the information provided to the patient.  • To review the patient as agreed intervals and copy all relevant results to the GP  • Carry out disease and drug monitoring as listed below  • Formally hand over to GP by letter and patient informed Prescribing:  • Initiate treatment with ciclosporin. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it has been initiated. Disease & drug monitoring:  • Monitor bloods according to schedule:  • Discuss shared care arrangement with patient.  • Support and advise GPs as required.  • Assess response to treatment and initiate any dose changes as clinically appropriate including discontinuation of treatment. Blood pressure Baseline In Rheumatic and connective tissue disease Serum creatinine needs to be measured at least twice before commencing treatment. In cutaneous disease A dermatological and physical examination including blood pressure and renal function required before starting. Urinalysis FBC U+Es LFTS Urate and lipids 24 hour urine creatinine clearance Blood pressure Then every 2 weeks until stable dose reached for more than 6 weeks and no change in NSAID therapy (RA patients). U+Es FBC LFTS Lipids After the first 2-3 months of treatment. Responsibilities of the General Practitioner General and Prescribing:  • Monitor and prescribe as recommended by the specialist. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it has been initiated or when the patient is on a stable dose.  • Vaccinations – note annual influenza vaccine and single dose pneumococcal vaccine should be offered unless otherwise advised by the specialist.  • If patients are exposed to chickenpox or shingles, passive immunisation should be carried out using varicella zoster immunoglobulin. Please contact consultant microbiologist for further advice or refer to the green book (chapter 34).  • Notify specialist if treatment with ciclosporin is discontinued or if unable to take on shared care..  • Ensure there are no drug interactions with any other medications initiated in primary care.  • Prescribe by brand Disease & drug monitoring:  • Carry out drug monitoring as listed – and communicate abnormal results to the specialist.  • Ensure the correct brand of ciclosporin is prescribed as stated by the prescriber.  • Urgent drug discontinuation/ referral to specialist as clinically appropriate  • To stop treatment on the advice of the specialist.  • To refer back to the specialist if the patient’s condition deteriorates.  • To identify adverse effects if the patient presents with any signs and liaise with the hospital specialist where necessary. To report adverse effects to the specialist and where appropriate to the Commission on Human Medicines/MHRA (Yellow Card scheme). Unless otherwise stated by the secondary care specialist, apply the following monitoring frequencies following handover from secondary care: Discontinue ciclosporin and seek advice from initiating team if: Neutrophils <1.6x 109/L AST or ALT >3 times upper limit of normal Blood pressure Monthly for 4 months then every 3 months. On dose increase – at week 2,4, 8 and then every 3 months as above. U+Es FBC LFTs Lipids Every 3 months. If no change at 6 months stop monitoring routinely At consultations Ask about oral ulceration, unexplained bruising/ bleeding, rash, sore throat. Platelets <140 x109/L Blood pressure >160/95 or risen >20mmHg (despite the addition of standard antihypertensive therapy. Potassium >5.5mmol/l Creatinine clearance Rises by >30% of baseline on 2 consecutive occasions one week apart. Lipids Significant rise Tremor/ gingivalhyperplasia/ hirsutism/ confusion Responsibilities of the Patient / Carer: General :  • Report any possible side effects to their GP, in particular potential signs and symptoms of bone marrow suppression (e.g. unexplained bruising, bleeding, sore throat, infection etc.)  • Practice safe exposure to the sun  • Ensure they have adequate supply of medication.  • Attend appointments including those for drug monitoring.  • Discuss options if considering pregnancy with GP/specialist  • To notify the Dr issuing prescriptions (hospital or GP) if wishing to start any new medication purchased over the counter (including herbal remedies) Communication Specialist to GP:  The specialist will inform the GP when they have initiated ciclosporin and when there are any subsequent changes in treatment.  Inform the GP of the information provided to the patient  Ensure that brand of ciclosporin has been communicated with GP GP to Specialist:  To inform specialist if not able to take on the monitoring and prescribing  Irrespective of whether prescribing responsibility has been accepted or not, inform the consultant of relevant medical information regarding the patient and changes to the patient’s medication regime irrespective of indication.  Notify specialist if treatment with ciclosporin discontinued. Specialist Contacts Department of Rheumatology – 01423 553389 Department of Dermatology – 01423 553740)

xx/xxx. Duration of Treatment Long term Dermatology patients: 6 moths to 1 year in majority of patients Responsibilities of the specialist initiating treatment General:  • To assess the suitability of the patient for treatment.  • To ensure that the patient/carer has received counselling and understands the therapy, its benefits, limitations, continued monitoring (where applicable), adverse effects.  • Inform the GP of the information provided to the patient.  • To review the patient as agreed intervals and copy all relevant results to the GP  • Carry out disease and drug monitoring as listed below  • Formally hand over to GP by letter and patient informed Prescribing:  • Initiate treatment with ciclosporin. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it it. has been initiated. Disease & drug monitoring:  • Monitor bloods according to schedule:  • Discuss shared care arrangement with patient.  • Support and advise GPs as required.  • Assess response to treatment and initiate any dose changes as clinically appropriate including discontinuation of treatment. Responsibilities of the General General and Prescribing: • Monitor and prescribe as recommended by the specialist. The Blood pressure Baseline In Rheumatic and connective tissue disease Serum creatinine needs to be measured at least twice before commencing treatment. In cutaneous disease A dermatological and physical examination including blood pressure and renal function required before starting. Urinalysis FBC U+Es LFTS Urate and lipids 24 hour urine creatinine clearance Blood pressure Then every 2 weeks until stable dose reached for more than 6 weeks and no change in NSAID therapy (RA patients). U+Es FBC LFTS Lipids After the first 2-3 months month of treatment. Responsibilities of the General Practitioner General and Prescribing:  Monitor and prescribe as recommended by the specialist. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately 2 months after it has been initiated or when the patient is on a stable dose.  • Vaccinations – note annual influenza vaccine and single dose pneumococcal vaccine should be offered unless otherwise advised by the specialist.  • If patients are exposed to chickenpox or shingles, passive immunisation should be carried out using varicella zoster immunoglobulin. Please contact consultant microbiologist for further advice or refer to the green book (chapter 34).  • Notify specialist if treatment with ciclosporin is discontinued or if unable to take on shared care..  • Ensure there are no drug interactions with any other medications initiated in primary care.  • Prescribe by brand Disease & drug monitoring:  • Carry out drug monitoring as listed – and communicate abnormal results to the specialist.  • Ensure the correct brand of ciclosporin is prescribed as stated by the prescriber.  • Urgent drug discontinuation/ referral to specialist as clinically appropriate  • To stop treatment on the advice of the specialist.  • To refer back to the specialist if the patient’s condition deteriorates.  • To identify adverse effects if the patient presents with any signs and liaise with the hospital specialist where necessary. To report adverse effects to the specialist and where appropriate to the Commission on Human Medicines/MHRA (Yellow Card scheme). Unless otherwise stated by the secondary care specialist, apply the following monitoring frequencies following handover from secondary care: Discontinue ciclosporin and seek advice from initiating team if: WCC <3.5x109 /L Neutrophils <1.6x 2 x 109/L AST or ALT >3 times upper limit of normal Platelets <140 x109/L Blood pressure Monthly for 4 months then every 3 months. On dose increase – at week 2,4, 8 and then every 3 months as above. U+Es FBC LFTs Lipids Every 3 months. If no change at 6 months stop monitoring routinely At consultations Ask about oral ulceration, unexplained bruising/ bleeding, rash, sore throat. Platelets <140 x109/L Blood pressure >160/95 or risen >20mmHg (despite the addition of standard antihypertensive therapy. Potassium >5.5mmol/l Creatinine clearance Rises by >30% of baseline on 2 consecutive occasions one week apart. Lipids Significant rise Tremor/ gingivalhyperplasia/ hirsutism/ confusion Responsibilities of the Patient / Carer: General :  • Report any possible side effects to their GP, in particular potential signs and symptoms of bone marrow suppression (e.g. unexplained bruising, bleeding, sore throat, infection etc.)  • Practice safe exposure to the sun  • Ensure they have adequate supply of medication.  • Attend appointments including those for drug monitoring.  • Discuss options if considering pregnancy with GP/specialist  • To notify the Dr issuing prescriptions (hospital or GP) if wishing to start any new medication purchased over the counter (including herbal remedies) Communication Specialist to GP:  The specialist will inform the GP when they have initiated ciclosporin and when there are any subsequent changes in treatment.  Inform the GP of the information provided to the patient  Ensure that brand of ciclosporin has been communicated with GP GP to Specialist:  To inform specialist if not able to take on the monitoring and prescribing  Irrespective of whether prescribing responsibility has been accepted or not, inform the consultant of relevant medical information regarding the patient and changes to the patient’s medication regime irrespective of indication.  Notify specialist if treatment with ciclosporin discontinued. Specialist Contacts Department of Rheumatology – 01423 553389 Department of Dermatology – 01423 553740)

xx/xxx. Duration of Treatment Long term Dermatology patients: Time to response is normally between 6 moths to 1 year in majority of patients weeks and 3 months but is likely dependent on indication. Treatment can be lifelong. Responsibilities of the specialist initiating treatment General:  • To assess the suitability of the patient for treatment.  • To ensure that the patient/carer has received counselling and understands the therapy, its benefits, limitations, continued monitoring (where applicable), adverse effects.  • Exclude pregnancy before starting treatment and advise patient to use contraception during therapy and for 6 weeks after stopping. • Inform the GP of the information provided to the patient.  • To review the patient as agreed intervals and copy all relevant results to the GP  • Carry out disease and drug monitoring as listed below  • Formally hand over to GP by letter and patient informed Prescribing:  • Initiate treatment with ciclosporinMycophenolate. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin approximately .Mycophenolate. Approximately 2 months after it has been initiated. Disease & drug monitoring:  • Monitor bloods according to schedule:  • Discuss shared care arrangement with patient.  • Consider pregnancy test if appropriate. • Support and advise advice GPs as required.  • Assess response to treatment and initiate any dose changes as clinically appropriate including discontinuation of treatment. Blood pressure Baseline In Rheumatic and connective tissue disease Serum creatinine needs to be measured at least twice before commencing treatment. In cutaneous disease A dermatological and physical examination including blood pressure and renal function required before starting. Urinalysis FBC U+Es LFTS Urate and lipids 24 hour urine creatinine clearance Blood pressure Then every 2 weeks until stable dose reached for more than 6 weeks and no change in NSAID therapy (RA patients). U+Es FBC LFTS Lipids After the first 2-3 months of treatment. Responsibilities of the General Practitioner General and Prescribing:  • Monitor and prescribe as recommended by the specialist. The GPs will be typically asked to take up the monitoring and prescribing of ciclosporin Mycophenolate approximately 2 months after it has been initiated. • Notify Consultant if treatment with Mycophenolate is discontinued or if unable to take on shared care • Ensure there are no drug interactions with any other Medications initiated or when the patient in primary care. • Annual flu vaccination is on a stable doserecommended.  Vaccinations – note annual influenza vaccine and single dose pneumococcal vaccine should be offered unless otherwise advised by the specialist.  If patients are exposed to chickenpox or shingles, passive immunisation should be carried out using varicella zoster immunoglobulin. Please Test Baseline Frequency Hepatitis B and C HIV Consider Varicella immune status √ (avoid if recurrent herpes/shingles0 BP, CrCL, √ FBC/ U+E/ LFT/ √ two weekly until on stable dose for 6 weeks then monthly for 3 months, then 3 monthly thereafter contact consultant microbiologist for further advice or refer to the green book (chapter 34).  Notify specialist if treatment with ciclosporin is discontinued or if unable to take on shared care..  Ensure there are no drug interactions with any other medications initiated in primary care.  Prescribe by brand Disease & drug monitoring:  • Carry out drug monitoring as listed – and communicate abnormal results to the specialistSpecialist.  Ensure the correct brand of ciclosporin is prescribed as stated by the prescriber.  • Urgent drug discontinuation/ referral to specialist as clinically appropriate  • To stop treatment on the advice of the specialist.  • To refer back to the specialist Specialist if the patient’s condition deteriorates.  • To identify adverse effects if the patient presents with any signs and liaise with the hospital specialist Specialist where necessary. • To report adverse effects to the specialist Specialist and where appropriate to the Commission on Human Medicines/MHRA (Yellow Card scheme). • Consider bronchiectasis or pulmonary fibrosis if patients develop persistent respiratory symptoms. Unless otherwise stated by the secondary care specialistSpecialist, apply the following monitoring frequencies following handover from secondary care: Test Frequency FBC/U+E/LFT Monthly for 3months then every 12 weeks Dose increases chould be monitored by FBC and LFTs at 2 and 6 weeks and then as above. Discontinue ciclosporin mycophenolate and seek advice from initiating team if: Neutrophils <1.6x 1.6 x 109/L AST or ALT >3 times upper limit of normal Blood pressure Monthly for 4 months then every 3 months. On dose increase – at week 2,4, 8 and then every 3 months as above. U+Es FBC LFTs Lipids Every 3 months. If no change at 6 months stop monitoring routinely At consultations Ask about oral ulceration, unexplained bruising/ bleeding, rash, sore throat. Platelets <140 x109/L Blood pressure >160/95 Patients should be warned to report immediately any signs or risen >20mmHg (despite the addition of standard antihypertensive therapy. Potassium >5.5mmol/l Creatinine clearance Rises by >30% of baseline on 2 consecutive occasions one week apart. Lipids Significant rise Tremor/ gingivalhyperplasia/ hirsutism/ confusion Responsibilities of the Patient / Carer: General :  Report any possible side effects to their GP, in particular potential signs and symptoms of bone marrow suppression (e.g. unexplained bruising, infection or bruising or bleeding, sore throat, infection etc.)  Practice safe exposure to the sun  Ensure they have adequate supply of medication.  Attend appointments including those for drug monitoring.  Discuss options if considering pregnancy with GP/specialist  To notify the Dr issuing prescriptions (hospital or GP) if wishing to start any new medication purchased over the counter (including herbal remedies) Communication Specialist to GP:  The specialist will inform the GP when they have initiated ciclosporin and when there are any subsequent changes in treatment.  Inform the GP of the information provided to the patient  Ensure that brand of ciclosporin has been communicated with GP GP to Specialist:  To inform specialist if not able to take on the monitoring and prescribing  Irrespective of whether prescribing responsibility has been accepted or not, inform the consultant of relevant medical information regarding the patient and changes to the patient’s medication regime irrespective of indication.  Notify specialist if treatment with ciclosporin discontinued. Specialist Contacts Department of Rheumatology – 01423 553389 Department of Dermatology – 01423 553740