title: Primary care attitudes to methotrexate monitoring.
abstract: BACKGROUND
  Rheumatoid arthritis affects 1% of the UK population. First-line treatment is with the immunosuppressant, methotrexate (MTX). This is generally regarded as a safe and effective medication when taken at the right dose, with appropriate monitoring. Very occasionally it causes serious harm or death. In 2006, the National Patient Safety Agency issued a safety alert following increasing reports of prescribing errors and toxicity. Over the last decade, Northwick Park Hospital has seen two MTX-related deaths and other morbidity. Repeat prescriptions and monitoring are generally undertaken in primary care, although concerns have been raised about variation in local practice. Poor communication and inadequate monitoring are safety concerns. Duplication of monitoring has cost implications. Local (hospital Shared Care Guidelines (SCG) ) and national guidelines, from the British Society of Rheumatology (BSR), on MTX monitoring are freely available and accessible.
  
  
  METHODS
  We surveyed our local GP community to better understand their practice and establish where patient care could be improved.
  
  
  RESULTS
  We contacted 86 practices, of which 31 replied (a response rate of 36%). On average, there was one patient on MTX per 743 in the practice (0.13%), ranging from 0-0.5%. All GPs admitted they repeated MTX prescriptions, but only 77.4% monitored these. Of those who did monitor, 58.6% were aware of local guidelines and only 48.4% were aware of national guidelines. A total of 26.7% of GPs were monitoring and prescribing MTX but not aware of any guidelines. Among this number, 37.5% did not feel they needed further education.
  
  
  CONCLUSIONS
  Serious safety concerns have been raised, including the poor response rate. Any doctor prescribing MTX should also be monitoring according to guidelines. Low numbers of patients on MTX per practice are surprising, possibly reflecting inadequate records or under-diagnosis. With these data, we have encouraged commissioners to fund a computer monitoring system accessible to primary and secondary care for improved patient safety, and to ultimately save costs by reducing duplication of work.
authors.affiliation: University College, London WC1E 6JF, UK. r.byng-maddick@ ucl.ac.uk
authors.forename: Rachel
authors.initials: R
authors.lastname: Byng-Maddick
authors.forename: Madhavi
authors.initials: M
authors.lastname: Wijendra
authors.forename: Henry
authors.initials: H
authors.lastname: Penn
mesh_terms: D018501:Antirheumatic Agents / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001291:Attitude of Health Personnel; D016903:Drug Monitoring / Q000706:statistics & numerical data*; D058005:General Practitioners; D019983:Guideline Adherence; D006801:Humans; D008727:Methotrexate / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D006113:United Kingdom / Q000453:epidemiology
chemical_list: D018501:Antirheumatic Agents; D008727:Methotrexate