Shared Care Protocol Research Articles

Enhancing clinical service design for multimorbidity management: A comprehensive approach to joined-up care for diabetes, chronic kidney disease, and heart failure.

Multimorbidity is becoming the norm rather than the exception, especially among the ageing population and people with lower socio-economic status. In addition to the rising healthcare cost, multimorbidity poses considerable difficulty in the delivery of adequate holistic care for affected patients. This review presents a discussion of the current barriers to delivering holistic care to people with multimorbidity and proposes a model of clinical care for people living with cardiovascular-kidney-metabolic (CKM) syndrome as an exemplar of a multimorbidity cluster. Single organ/disease services may not be able to provide optimum care to people with multimorbidity due to the potential complex interactions between multiple disease symptoms and management. In addition, people with multimorbidity may be required to attend multiple appointments in different healthcare centres. This may negatively impact access to services due to time and financial burden. Other barriers include co-ordinating communication between healthcare professionals and reduced continuity of care. Optimising CKM health requires patient-centred care led by an interdisciplinary care team who ideally should possess CKM competencies utilising a shared care protocol to coordinate evidence-based care and use of telehealth to empower patients. Stakeholders and policymakers need to adapt new policy models to establish and enhance CKM care models by allocating funds and implementing frameworks for educational reforms. A CKM service has the potential to increase the uptake of cardiac and renal protective medications as well as optimising metabolic care, increase capacity in both primary and secondary care, improve quality of life and clinical outcomes, reduce patient inconvenience, and importantly allow rapid translation of advances in cardiorenal metabolic diseases into clinical practice.

Protocols for Oral Health Management of Paediatric Patients with Inherited Bleeding Disorders: A Narrative Review

Introduction: The provision of dental care for paediatric patients with inherited bleeding disorders (IBD) can present a challenging scenario for dentists. Although patients with a low bleeding risk can safely receive preventive procedures in the community, many dentists lack confidence when treating this cohort. Consequently, most patients with IBD are seen in hospital dental clinics. There is currently no protocol for shared delivery of primary dental care for paediatric patients with IBD in Australia. Aim: To provide a narrative review of the protocols for oral health management of paediatric patients with inherited bleeding disorders. Materials and methods: An electronic search of four databases relating to the oral health management and outcomes of paediatric patients with IBD was conducted. Results: Thirty-eight papers were included in this review. Several patient and clinician factors in accessing and providing dental care for paediatric patients with IBD were identified. IBD specific considerations for the provision of safe dental care were discussed relating to elective and emergency dental management principles. There was a paucity of paediatric specific protocols for dental management of children with IBD, with only one paediatric specific shared care protocol identified in this review. Conclusions: This review has highlighted the need for further exploration into patient and clinician related barriers and enabling factors in accessing and providing primary dental care for paediatric patients with IBD. The development of a shared model of care between community and hospital dental clinics may improve both clinician and patient experiences in providing and accessing safe dental care.

Step-Wise Management of Anemia in Patients With Chronic Kidney Disease in Primary Care: Qualitative Study.

Anemia is common in chronic kidney disease (CKD) and is associated with increased cardiovascular risk and reduced quality of life, but is often sub-optimally managed. Most patients are managed in primary care alongside other comorbidities. Interventions to improve the management of anemia in CKD in this setting are needed. We conducted a qualitative study to evaluate how an audit-based education (ABE) intervention might improve the management of anemia in CKD. We explored outcomes that would be relevant to practitioners and patients, that exposed variation of practice from National Institute for Health and Care Excellence (NICE) guidelines, and whether the intervention was feasible and acceptable. Practitioners (n = 5 groups) and patients (n = 7) from 4 London general practices participated in discussions. Practitioners welcomed the evidence-based step-wise intervention. However, prescribing erythropoiesis-stimulating agents (ESAs) was felt to be outside of their scope of practice. There was a gap between NICE guidance and clinical practice in primary care. Iron studies were not well understood and anemia management was often conservative or delayed. Patients were often unaware of having CKD, and were more concerned about their other comorbidities, but largely trusted their GPs to manage them appropriately. The first steps of the intervention were welcomed by practitioners, but they expressed concerns about independently prescribing ESAs. Renal physicians and GPs could develop shared care protocols for ESA use in primary care. There is scope to improve awareness of renal anemia, and enhance knowledge of guideline recommendations; and our intervention should be modified accordingly.

P281 TELEIBD: A telematic fast-track pathway for patients with high suspicion of Inflammatory Bowel Disease in primary care

Abstract Background The incidence and prevalence of Inflammatory bowel disease (IBD) are increasing in the last years. In primary care (PC) patients often present with confusing and non-specific symptoms which can often be a delay in referring and diagnosing suspected IBD. The average time from symptom onset to diagnosis of IBD is longer than five years in up to 18% of cases and 64% of patients presenting to emergency care with symptoms of IBD prior to the diagnosis. Shared care protocols and closer working with integrated care teams can bridge the gap between primary and specialized care, improving their assistance Methods This is a retrospective study that evaluates the results of TELEIBD (telematic circuit care) in patients with high diagnostic suspicion of IBD between PC and IBD Unit of our health area since its implementation in August 2019 to October 2020. The number of telematic consultations, average resolution time, adaptation to referral criteria, complementary tests requested and diagnostic confirmation were evaluated. TELEIBD establishes the issuance of a telematic consultation through the electronic clinical history when a patient meets previously established criteria. Specialized IBD physician who evaluates the case, can advise a diagnostic or therapeutic attitude either by electronic means or face-to-face with the patient. Results A total number of 77 care consultations from 77 patients (58,4% females) have been made. The average age was 49,2 years and the average reponse time were 7,5 days. After teleconsultation, 46 patients (59.7%) were not requested medical test. Lower gastrointestinal endoscopy (LGE) was performed in 25 patients, blood and faecal calprotectin testing in 7 patients, magnetic resonance (MR) or computer tomographic (CT) enterography in 6 patients. Taking into account the criteria for referral to a specialist, a total of 15 patients (19,5%) fully met the criteria, 13 patients (16,9%) partially met the criteria and 49 patients (63,6%) did not meet it. The main reason fot not meeting the criteria were the inadequated use of TELEIBD (53,1%). Of the 25 LGE requested, 3 were suggestive of Ulcerative Colitis (UC) and 1 of Crohn’s Disease (CD). Diagnosis of CD was confirmed in 2 patients, using MR or CT enterography. Diagnoses were reached in 4 patients, 3 of the group that met referral criteria (20%) and 1 of the group that partially met it (7.7%). The diagnosis was not achieved in any patient who did not partially and/or fully meet the referral criteria. Conclusion TELEIBD can be a useful tool for the quick assessment of patients who meet the criteria for high suspicion of IBD. Training primary care physicians in the referral criteria of the pathway is essential to improve the functioning of the circuit.

Efficacy of a multidisciplinary care protocol for the treatment of operated hip fracture patients

To assess the effects of a multidisciplinary care protocol on cost, length of hospital stay (LOS), and mortality in hip-fracture-operated patients over 65 years. Prospective cohort study between 2011 and 2017. The unexposed group comprised patients who did not receive care according to the multidisciplinary protocol, while the exposed group did. Variables analyzed were demographics, medical comorbidities, treatment, blood parameters, surgical delay, LOS, re-admissions, mortality, and a composite outcome considering in-hospital mortality and/or LOS > 10 days. We performed a Poisson regression and cost analysis. The cohort included 681 patients: 310 unexposed and 371, exposed. The exposed group showed a shorter surgical delay (3.0 vs. 3.6 days; p < 0.001), and a higher proportion received surgery within 48 h (46.1% vs. 34.2%, p = 0.002). They also showed lower rates of 30-day readmission (9.4% vs. 15.8%, p = 0.012), 30-day mortality (4.9% vs. 9.4%, p = 0.021), in-hospital mortality (3.5% vs. 7.7%; p = 0.015), and LOS (8.4 vs. 9.1 days, p < 0.001). Multivariable analysis showed a protective effect of the protocol on the composite outcome (risk ratio 0.62, 95% CI 0.48–0.80, p < 0.001). Hospital costs were reduced by EUR 112,153.3. A multidisciplinary shared care protocol was associated with a reduction in the LOS, surgical delay, 30-day readmissions, and in-hospital and 30-day mortality, in hip-fracture-operated patients.

Decentralising NCD management in rural southern Africa: evaluation of a pilot implementation study

BackgroundThe prevalence of non-communicable diseases, and associated morbidity and mortality, is increasing rapidly in low and middle-income countries where health systems often have limited access and lower quality of care. The intervention was to decentralise uncomplicated non-communicable disease (NCD) care from a hospital to nurse practitioners in health centres in a poor rural district in Eswatini, southern Africa. The objective of this study was to assess the feasibility and impact of decentralised care for NCDs within nurse-led clinics in order improve access and inform healthcare planning in Eswatini and similar settings.MethodsIn collaboration with the Eswatini Ministry of Health, we developed and implemented a package of interventions to support nurse-led delivery of care, including: clinical desk-guide for hypertension and diabetes, training modules, treatment cards and registries and patient leaflets. Ten community clinics in the Lubombo Region of Eswatini were randomly selected to be trained to deliver NCD care for a period of 18 months. Observational data on follow-up rates, blood pressure (BP), glucose etc. were recorded and evaluated. We compared blood pressure and blood glucose measurements between the first and fourth visits and fitted a linear mixed effects model.ResultsOne thousand one hundred twenty-five patients were recruited to the study. Of these patients, 573 attended for at least 4 appointments. There was a significant reduction in mean BP among hypertensive patients after four visits of 9.9 mmHg systolic and 4.7 mmHg diastolic (p = 0.01), and a non-significant reduction in fasting blood glucose among diabetic patients of 1.2 mmol/l (p = 0.2). Key components of NCD care were completed consistently by nurses throughout the intervention period, including a trend towards patients progressing from monotherapy to dual therapy in accordance with prescribing guidelines.ConclusionsThe findings suggest that management of diabetes and hypertension care in a rural district setting can be safely delivered by nurses in community clinics according to a shared care protocol. Improved access is likely to lead to improved patient compliance with treatment.

Shared care pitfalls: high dose antipsychotic monitoring in the community

BackgroundShared care is an integral part of monitoring patients on high-dose antipsychotics (HDA). These off-label prescription medications used for treatment resistant schizophrenia carry significant risk of harm, including sudden death. The challenges of monitoring HDA prescriptions are complex in the community setting.AimIdentify pitfalls in community HDA prescribing and monitoring through an audit of a busy London adult psychosis service caseload.MethodTwo years on from an initial caseload audit and multidisciplinary team education programme, compliance on HDA monitoring forms was re-audited in greater depth. Correspondence between the community psychiatric team and each patient’s GP was reviewed, looking for evidence of shared care protocols. Results were combined with a literature search.ResultsNone of monitoring tests were adequately recorded. In 100% of cases windows for repeat ECG and observation monitoring had been missed. In 100% of cases blood tests had been carried out by the GP but this information was not documented appropriately. 0% of case records showed clear documentation of the shared care protocol from psychiatric team to GP.ConclusionHDA psychotic monitoring policies has been poor when audited at inpatient centres, however, these audits have led to improvements in guideline compliance. In this case, MDT education failed to lead to improvement. The primary–secondary care interface leaves GPs lacking certainty in their roles monitoring HDAs. Patients in the community are not always stable enough to have the insight or motivation to consistently engage with services. New strategies with a focus on shared care have been implemented to drive quality improvement.

Priorización de herramientas para la integración entre atención primaria y hospitalaria: encuesta sobre expectativas y creencias de los profesionales

IntroductionIntegrated care is a top priority for most of the National Health Services. In this study, an evaluation is made on the professional's beliefs and expectations regarding integration. Material and methodsBetween March and June 2017, Health Professionals from El Bierzo, León, Spain, were invited to complete 2 questionnaires on health integration process, including an online questionnaire on patient care integration (405 and 211 participants, respectively out of the total 1854 professionals). ResultsThree out of four professionals pointed at communication as the most important factor to achieve integration. Medical records, Health Care Education and medication reconciliation were the other prioritised factors. Care pathways (98%), nurse navigator (93%) or shared care protocols (92%) were highly recommended. The entire Hospital Service (55%) was the preferred link, with Primary Care versus a single consultant for every Primary Care Centre (29%), or for all the whole area (16%).There were no differences between primary and hospital services in most of the tools assessed. ConclusionsCommunication tools are the cornerstone to achieve a successful integration of the care services according to Health Professionals.

Examining Shared-Care Models for the Long-Term Management of Stable Kidney Transplant Recipients

Background Advances in transplantation procedures, immunosuppressive agents, and the management of comorbid conditions have led to better outcomes in kidney transplant recipients (KTR). The subsequent rise in the number of KTR and the duration of post-transplant follow-up care places a strain on the limited resources of specialized transplant centres. Thus, innovative models of long-term care for KTR is needed to alleviate this strain and improve the capacity of these centres. Shared-care practices, integrating community nephrologists with the transplant team, is an approach to improve the efficiency and quality of care provided to stable KTR. A literature review was conducted to investigate existing shared-care models in KTR while a scoping review was conducted to further explore shared care models in chronic disease management. Methods For the primary literature review, Medline and CINAHL were searched with keywords including “kidney transplant”, “long-term”, “community”, and “care”. For the scoping review, Medline was searched with terms including “diabetes”, “heart failure”, “shared-care”, “long-term”, and “care”. We included peer-reviewed articles and abstracts published in English from 1970 to 2016. Two reviewers independently assessed and extracted data from included articles. Results After screening 1053 articles for the primary search, 13 were found eligible and included in the review. The articles from the primary search separated into two major themes: articles explaining shared care protocols for the long-term management of KTR and articles summarizing clinical management strategies after transplantation. Four articles described specific shared-care models with community nephrologists by suggesting a timeline for transfer and follow-up, outlining guidelines for communication, and identifying possible setbacks to implementation. Due to limited information obtained on implementation and evaluation of shared-care models, we expanded our review to consider models used in the management of heart failure and diabetes. Some important factors in the implementation of shared-care for these complex conditions included the role of a specialist nurse to facilitate coordination between centres as well as standardized clinical and referral guidelines. Shared-care practices generally resulted in improvements in information exchange and received positive responses from patients and healthcare staff. Patient health outcomes were found to be at least comparable to (and sometimes better than) less collaborative models. Conclusion While a standardized shared-care model for the management of stable KTR has not yet been established, sharing of patient care responsibilities between the transplant center and community nephrologists optimizes access to post-transplant care, may improve the quality of care, and reduces the burden on transplant centres.

Management of Adults With Congenital Heart Disease and Pulmonary Arterial Hypertension in the UK: Survey of Current Practice, Unmet Needs and Expert Commentary

Pulmonary arterial hypertension (PAH) is a well-recognised complication of adult congenital heart disease (CHD). However, management is not currently standardised between centres and specific guidelines are lacking. In order to identify and understand the unmet needs related to PAH associated with CHD (PAH-CHD), a survey of physicians was performed. An electronic survey was sent to two physician groups: (1) cardiologists registered in a UK cardiology directory; (2) specialist pulmonary hypertension (PH) physicians known to manage patients with adult PAH-CHD. The questions related to referral pathways, screening, therapy and palliative care. 821 surveys were distributed and 106 were returned. Respondents included a broad mix of specialist physicians with many patients along with general cardiologists managing only a small number of PAH-CHD patients. Although 97% of respondents have access to a specialist PH centre, patients are still being managed in non-specialist settings. Shared care arrangements are widespread but only 41% have formal shared care protocols. Palliative care services are limited and general cardiologists rarely perform 6-minute walk tests (6MWT) or quality of life assessments. People with PAH-CHD are often undertreated, with 39% of respondents reporting that fewer than 25% of these patients were receiving PAH-specific therapies. The survey revealed gaps and inconsistencies in the management of patients with PAH-CHD therefore patient-specific guidance is needed for many of these aspects.

Delivering Person-Centric, Seamless Care through the Patient Appointment Consolidation (PAC) Programme

Introduction: The prevalence of patients with multiple chronic diseases is rising both globally and in Singapore. Our healthcare systems, currently centred around acute hospitals, are largely configured to manage individual diseases rather than multimorbidity, resulting in such patients seeking care from multiple specialists. This can result in care fragmentation, duplication of efforts, increased healthcare cost, long waiting times, and delayed treatment for those in need of specialist services. Furthermore, patients may seek care from both tertiary and primary care settings, which may not be well integrated. The National University Health System Regional Health System (NUHS RHS) thus started the Patient Appointment Consolidation (PAC) programme in 2014 to deliver more seamless, person-centric care to patients with multiple co-morbidities through consolidation under a primary physician. Care Model: Primary care coordinators (PCCs) assist clinicians to identify suitable patients with multiple specialist outpatient appointments for consolidation of care under a primary physician within the hospital or a dedicated family physician in the community. The PCCs counsel patients on the available options, schedule appointments and also provide patient and caregiver education on disease management. Once enrolled on the programme, each patient is well-supported by a multi-disciplinary team comprising hospital specialists, primary care physicians, nurses and allied health professionals. This programme has garnered support from various stakeholders and fostered collaboration between the public healthcare sector, i.e. acute hospital and private sector, i.e. primary care partners to develop shared care protocols for holistic patient management. This partnership has been facilitated by a common EMR platform, allowing family physicians in the community to access clinical notes from hospital specialists and vice versa for the specialists to continue monitoring their patients’ conditions as they are being cared for in the community. Family physicians and specialists could discuss patient cases and treatment plans directly through the common EMR platform, phone calls or meetings. Duplications of tests are also avoided, as test results are recorded in the shared platform. Outcomes: Analysis of 107 patients with propensity matched controls showed that there were statistically significant reductions (p<0.01) in number of specialties attending to each patient by 0.53 and per patient SOC visits by 1.78 per year. Reductions in Length of Stay (LOS), visit to Emergency Department and admission of each patient were 3.19, 0.24 and 0.07 respectively in a year, but were not statistically significant. Net system cost savings were estimated to be S$492 (~USD$342) per patient in a year. For successful programme implementation, dedicated PCCs, clinicians’ buy-in, patients’ mindset change on care model, availability of subsidies to increase patients’ willingness to be managed in the community, and shared EMR system are identified as crucial factors. To ensure programme sustainability, programme team would continue to facilitate regular communication between the SOC and primary care to enable deeper engagement, enhance mutual confidence and build rapport and trust between the stakeholders. Escalation workflows have also been established to ensure that patients are well-supported with specialist care when needed. To allow for further programme refinement, NUHS RHS has embarked on a comprehensive mixed methods research study to better understand outcomes at the patient, programme and healthcare system levels. Learnings from such a model could potentially be tailored and adopted by other health systems.

Prescribing dronedarone for paroxysmal atrial fibrillation: how is it done across the UK and is it safe?

Dronedarone, a useful treatment for paroxysmal atrial fibrillation, is often only prescribed in secondary care. To support a protocol shared between primary and secondary care, dronedarone use was audited in...

Improving specialist drug prescribing in primary care using task and error analysis: an observational study.

Electronic prescribing has benefited from computerised clinical decision support systems (CDSSs); however, no published studies have evaluated the potential for a CDSS to support GPs in prescribing specialist drugs. To identify potential weaknesses and errors in the existing process of prescribing specialist drugs that could be addressed in the development of a CDSS. Semi-structured interviews with key informants followed by an observational study involving GPs in the UK. Twelve key informants were interviewed to investigate the use of CDSSs in the UK. Nine GPs were observed while performing case scenarios depicting requests from hospitals or patients to prescribe a specialist drug. Activity diagrams, hierarchical task analysis, and systematic human error reduction and prediction approach analyses were performed. The current process of prescribing specialist drugs by GPs is prone to error. Errors of omission due to lack of information were the most common errors, which could potentially result in a GP prescribing a specialist drug that should only be prescribed in hospitals, or prescribing a specialist drug without reference to a shared care protocol. Half of all possible errors in the prescribing process had a high probability of occurrence. A CDSS supporting GPs during the process of prescribing specialist drugs is needed. This could, first, support the decision making of whether or not to undertake prescribing, and, second, provide drug-specific parameters linked to shared care protocols, which could reduce the errors identified and increase patient safety.

The efficacy of a shared-care surveillance protocol for asymptomatic renal calculi

Objective: Patients at our institution with asymptomatic calyceal stones (&lt;11 mm) are discharged to their GPs with a request for 12- and 24-month X-ray KUBs with specific re-referral criteria. We aimed to assess the effectiveness of this shared care protocol as well as to investigate long-term outcomes. Patients and methods: All patients satisfying the above criteria discharged during October 2009–June 2011 were reviewed for protocol compliance, symptomatic events and/or surgical intervention up to July 2015. Results: A total of 134 patients were identified. Out of 115 patients eligible for their first X-ray, and 100 patients eligible for their second X-ray, 43% and 26% respectively were performed. Of these, 75% demonstrated no progression. No patients were treated surgically solely on the basis of radiographic progression. Over a mean five-year follow-up, patients had a 39% chance of experiencing a symptomatic event and a 24% chance of requiring surgical intervention (ESWL, ureteroscopy and/or PCNL). Risk factors included a previous stone history and having a total stone size &gt;10 mm. Conclusion: There was poor adherence to this protocol. Despite this, only symptomatic patients were treated surgically, challenging the value of indefinite surveillance of asymptomatic patients. Longitudinal studies are needed to determine a cost-effective manner in which these patients can be safely followed up.

EPA-0713 – Psychiatrists’ opinion in general practitioners’ referral letters

Primary and secondary care communication is the cornerstone of patient's care. Proper dialogue should be established. The shared care protocol was an attempt to try to fill gaps and build bridges. A special form was designed to collect information about psychiatrists’ opinion on GPs’ referral letter to psychiatric services. It contained 14 items, each item was marked as essential, can be included or irrelevant. This form was sent electronically to psychiatrists in Southessex University NHS Trust. They are 98 in total. It was input on Excel data sheet and was analysed. 43 psychiatrists responded All respondents agreed that reason for referral is essential. Concise description of the condition, risks and current medication were rated as essential in more than 90 %. Past medical history, past psychiatric history and current physical health were essential in 79 %. All professionals involved should participate in evaluating and refining communication. Psychiatrists’ opinion in GPs letters is paramount as they are the recipients and their assessments and future management plan should be geared to address the GP's concerns. This is shown clearly by the psychiatrists agreeing that reason for referral should be included in all letters, followed by what the GP has already done and what risks the patient presents. Improving communication between health professional, improve patient's care, saves time and money, in addition to prevent duplication of investigation and procedures.

OP0289 Comparative Knowledge and Perception of Two Chronic Diseases – Rheumatoid Arthritis and Diabetes Mellitus in Primary Care: Testing Waters Locally….

BackgroundGood medical practice for general practitioners, published by the Royal College of general practitioners in 2008, highlights the standard of practice for GPs in the delivery of care to patients....

PTU-095 A qualitative exploration of inflammatory bowel disease patient perceptions of primary care in the UK

IntroductionMany patients with IBD in the UK are managed primarily in secondary care with minimal General Practitioner (GP) involvement or within a restricted shared care protocol. As UK NHS hospitals...

P-879 - Critical analysis of GPs opinion in new patients psychiatric assessment letters

Background Primary and secondary care communication is the cornerstone of patient's care. In order to improve communication, proper dialogue should be done. The shared care protocol was an attempt to try to fill gaps and build bridges for more efficient integrated care. Methods A special form was designed. Each item was marked as essential, useful or irrelevant. This form was sent to 150 local GPs with a stamped addressed envelope. 106 response were received. It was input on Excel data sheet and was analysed. Results The majority agreed that date, place of clinic. Majority agreed that date, place of the clinic, diagnosis, current medication, mental state, risk assessment, current social situation, investigation arranged, other therapeutic interventions, involvement of other professionals, date of follow up and information given to patients are essential information in the letter. 100% agreed that change of medication and who will prescribe is essential. Less than 50% thought that inclusion of involvement of other agencies is essential. Discussion Clear, up to date communication between primary and secondary care is vital for good patient care. All people involved should participate in evaluation and refining ways of working. As GPs are the main recipients of new patients assessment letters, for that reason, their opinion should be taken. Change of medication and risk assessment are the most important information GPs highlighted as they help them in patient management. Conclusion Improving communication between health professionals, improve patient's care, saves time and money, in addition to preventing duplication of work.

Azathioprine induced hepatitis in patients with inflammatory bowel disease

I welcome Salem and colleagues recent article on Azathioprine induced cholestatic hepatitis [1]. Azathioprine is an immunosuppressant used in the management of a number of clinical conditions. Concerns at time of commencing azathioprine are related to bone marrow suppression, consequently the TPMT levels are checked to ensure appropriate dosing regimen. However, azathioprine induced hepatitis is a rare but serious problem, which manifests either as a problem associated with chronic use and a gradual derangement of liver function tests or more concerning an acute severe hepatitis occurring within weeks of commencing treatment. This latter presentation is well reported in the literature and demonstrated to occur in patients on azathioprine for a number of different clinical conditions. In our institution over the last 4 years there have been two patients with inflammatory bowel disease that developed severe hepatitis following commencement of azathioprine. In both cases, patients developed upper abdominal pain, nausea and felt generally unwell. Both patients denied taking other medications or herbal remedies at this time. The bloods tests demonstrated a negative liver screen (including viral hepatitis screen, immunoglobulins, ferritin, urinary copper, caeuroplasmin, liver autoantibodies). Both patients’ had a normal amylase and deranged liver function tests; with marked rise in bilirubin of [100 lmol/l, and associated transaminitis. Both these patients had normal TPMT levels ([25 pmol/h/mg), hence neither were heterozygote or homozygote for TPMT deficiency. The Naranjo ADR probability scale was applied to these cases, which determined that hepatitis was probably due to the azathioprine in both cases (Naranjo probability score of 5 in each case). Following worsening of liver function tests, the azathioprine was stopped in both cases; this lead to a complete resolution of abnormal liver biochemistry over a period of 4 and 6 weeks, respectively. Upon reviewing the literature regarding azathioprine induced hepatitis, TPMT deficiency was not recognized in a number of cases [2–4]. To date fortunately there have not been any deaths related to azathioprine induced hepatitis. In all published cases, liver function tests improve upon cessation of azathioprine. Currently there is no test available to identify which patients will develop severe azathioprine associated hepatitis. Therefore, it is our practice to monitor all patients commencing on azathioprine and we have a shared care protocol with the general practitioners. This involves full blood counts, renal and liver function tests being checked at weeks 2, 4 and 6 weeks following commencement of azathioprine. We recommend a similar pathways exist for all other specialties commencing patients on azathioprine to enable early detection of this rare but serious adverse effect of azathioprine. With reference to the article by Salem et al. [1], it is important to note that acute azathioprine associated hepatitis occurs in patients with normal TPMT as well as those with TPMT deficiency. Secondly, frequent and regular blood tests at commencement of therapy currently are the only way to determine if a patient is developing an acute hepatitis. R. Srirajaskanthan (&) D. Valliani University Hospital Lewisham, London, UK e-mail: r.srirajaskanthan@nhs.net

The medical management of inflammatory bowel disease in primary care: the north bristol experience

IntroductionEvidence suggests that Aminosalicylates (5-ASA) have a chemopreventative effect in reducing rates of CRC in patients with colitis.1 It is recommended that patients should be maintained on a dose of...