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N004. Successful, nurse-led, protocol-based, safety monitoring in IBD patients on thiopurines

J. Hughes1, J. Andrews1, R. Grafton1, 1Royal Adelaide Hospital, Gastroenterology, Adelaide, Australia

Background

Twenty seven percent (219) of our 800 IBD patients are on current thiopurine therapy.

For optimal safety we recommend regular monitoring of:

  • Full blood count and liver enzymes
  • Patient compliance and general well-being

With a limited number of medications available for the treatment of Inflammatory Bowel Disease, it is vital that maximum benefit is obtained from each medication.

Even with the provision of verbal and written information/instructions, many patients will not adhere to the schedule of blood testing recommended. The role of monitoring patients is carried out by IBD nurses at the Royal Adelaide Hospital, in order to provide an effective, patient-centred approach.

Methods

When a patient commences a thiopurine, an IBD nurse is notified. We commence with 50 mg and build up to target dose based on patient weight, to facilitate early detection of intolerance and to help minimize side effects. Our regime for blood testing is:

  • weekly until 4 weeks after target dose is reached
  • monthly for 3 months
  • 3 monthly thereafter.

The nurse follows up all results including those not done when due, thus avoiding the potential for only observing compliant/well patients. If the dose is increased at any stage, weekly testing is resumed for 4 weeks. Contact is made with the patient each week after receipt/non-receipt of results, for assessment of wellbeing and instructions on appropriate dose adjustments.

Results

Overall number monitored during 2012 (all frequencies) 219.

Intolerant/adverse event 51.

“Shunters” commenced on Allopurinol this year 16.

Reminders required (excluding weekly contact with novice patients) 350. Average/week 9.

Total blood tests reviewed 2012 to date 810. Average/week 20.

Conclusion

The IBD nurse is ideally suited to carry out this monitoring:

  • Able to recognize and reassure re minor side effects and investigate and implement treatment for major side effects.
  • Provides extra contact and continuity with patients at a vulnerable time.
  • Minimises those “lost to follow-up” allowing healthcare resources such as outpatient visits, to be more efficiently used.

This patient-centred approach minimises poor adherence to treatment and potentially avoidable flares or toxicities, which are all well-recognised problems in IBD. With this approach there has been no hospital admission or major myelosuppression this year.