Practice and Prescription Protocols for PsA


Shared insight on technical processes and protocols used to manage patients with psoriatic arthritis, including those for prescription fulfillment.


Michele M. Cerra, MSN, FNP-C:Do you have any practice protocols within your practice to increase compliance? For us at Duke [Duke University, Raleigh, North Carolina] we use nurse triage, which I’m very thankful to have. We have nurses that answer the phone [and] answer patient questions. [A] patient could be flaring and need to get an appointment for a joint injection, medication, maybe they’re not sure. An adverse effect, or it’s not effective. The nurses know they have practice protocols whether it's making them come in for lab work or a visit or just helping them to get connected to the pharmacy as far as getting drug. Do you have any specific protocols in place?

Nancy Eisenberger, MSN, FNP-C: Yes. We do the same thing. Also, if patients are going to use subcutaneous medications,most of the companies have programs that they’ll send a nurse to the house.

Michele M. Cerra, MSN, FNP-C:The nurse ambassadors are wonderful.

Nancy Eisenberger, MSN, FNP-C: Right now, with COVID-19, they’re doing it more on the phone or virtually, but it does help with compliance and it makes people feel special because they have us at the office and they also have somebody else they could call when they have a problem or question.

Michele M. Cerra, MSN, FNP-C:You see patients in 6 weeks if they’re started on [a] new drug. That’s wonderful. I wish I had more time to do that but what I do have is 1 of the other NPs [nurse practitioner’s] in the practice see them while I’m in the clinic and I can peek in on the patient. As far as patients who have been on [the] drug and are doing well, how often do you see them back in clinic for follow-up?

Nancy Eisenberger, MSN, FNP-C: Every 3 months. I like to keep an eye on making sure that they’re staying adherent with their medications and if they don’t have any questions or new symptoms that they haven’t noticed but I’ll notice when I examine them. I know some people with psoriatic arthritis [PsA] who will go longer but 3 months is appropriate for my patients.

Michele M. Cerra, MSN, FNP-C:That’s our practice protocol. At Duke we see patients every 12 weeks and then for patients who are stable maybe every 4 to 6 months with the understanding that if they think they’re flaring or having issues they need to come in sooner.

During the pandemic or in general because this is even difficult for me, how do you know your patients are filling their prescriptions because only occasionally will I get certain insurance companies [that] will send me a letter stating your patient hasn’t filled their drug since… it’s not all of them. So I’m not sure if my patients are refilling and staying on drug when they drop off and I don’t see them for 6 months, or they disappear for longer sometimes, but then occasionally I get a request, they want a refill.

Nancy Eisenberger, MSN, FNP-C: My triage department patients can’t get medicine filled without having their labs done. They’ll send it to immediately and say this patient’s requesting this, they haven’t been in in X amount of time, and we’ll set them up with a video or phone visit that day if that’s the case. The other thing in our EHR [electronic health record] I could look at all the pharmacies and see when my patients filled their medication and based on their request when it was last filled. This helps me understand, but if they’re not going to take their medicine, they’re not going to, but I will call them up, educate them, get them in video visit and find out what their concerns are. See if they want to do something different if they’re not going to take the medicine that they were taking. It’s a challenge. Also, we’re finding out that they were sick or something else and it’s something that we should know about, so keeping up with this is important.

Michele M. Cerra, MSN, FNP-C:Sometimes they’ve lost their job, they’ve been laid off, or maybe it’s through a divorce separation they’ve lost their insurance or a death of the spouse. Sometimes we don’t know the reasoning, but I usually don’t know unless I get a letter from the insurance or the patients email me or send me a MyChart message. It is hard to track these patients and then they’re usually showing up or wanting to go back on drug if they stop when they’re crashing and burning and their disease is just so out of control. That’s why we need to bring them back in and educate. All that inflammation is going through your bloodstream causing coronary artery disease, fatty liver disease, anemia. It’s just reeling them back in and educating them.

Nancy Eisenberger, MSN, FNP-C: And there’s lots of ways for us, if it’s a DMARD [disease-modifying anti-rheumatic drug], they could shop it around at different pharmacies if it’s a cost issue like that, they lost their jobs. Again, we could get them in the patient assistance programs if they’ve lost their jobs. Most of the big pharma companies have programs like that. Again, if we can pick up on this it’s great that we can help our patients continue to keep their inflammation in control.

Michele M. Cerra, MSN, FNP-C:Sometimes just the GoodRx card. I know we get those in our practice. Some patients they’ll even say I might have Medicare or commercial insurance but sometimes I say don’t even run it just use the GoodRx card and their drugs they can get a lot of cheaper. That’s kind of crazy [because] you would think insurance would cover me, but normally GoodRx they can get it a lot cheaper.

Transcript edited for clarity.

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