142. UPDATE ON THE INTRODUCTION OF DOSE TAPERING TO MODERNIzE AND IMPROVE THE BIOLOGICS SERVICE IN A DISTRICT GENERAL HOSPITAL

Abstract

Background: The Hereford rheumatology department has over 500 patients on biologics, with the number of new patients this calendar year increasing by 60% from the previous year. We commenced dose tapering in June 2015 as a response to the growth in prescribing of biologics. Increased biologic use cumulated in clinical and administrative pressures, in addition to increased expenditure. Evidence shows that for selected biologic patients in sustained remission, it is possible to taper the doses of biologic medication and maintain remission. This reduces patients' medication burden and side effects. Dose tapering has been integrated into a local gain share agreement, resulting in increased cost efficiencies and an improved biologics service. Methods: We developed a departmental dose tapering protocol for patients with RA and arranged an associated gain share agreement with our CCG. This involved participation from clinical staff, commissioners and hospital management. The protocol identifies those patients whose biologic doses may be effectively tapered, with disease activity being assessed by DAS28 score and ultrasound. Dose tapering is considered for ankylosing spondylitis (AS) and psoriatic arthritis (PsA) patients at the clinician's discretion, due to the relative lack of evidence in these groups. The savings provided funding for a biologics pharmacist, an additional administrative assistant, consultant time and ultrasound scanning. Newly emerging evidence is continuously reviewed and the protocol is updated accordingly. Our biologics database is subject to constant development resulting in more efficient monitoring of current and potential patients for dose tapering. Results: After 17 months, 58 patients' doses have been tapered, 44 RA, 5 AS and 9 PsA. 14 patients (12 RA and 2 PsA) have resumed their initial biologic dose thus far, due to flare of disease post-taper, which is in line with data from the literature. We have successfully funded the additional resources resulting in a more robust biologics service. The department has been subject to many advantages including reduced daycase infusions, therefore improving capacity problems and reducing tariff charges. Integrated working between medical, nursing, pharmacy and administrative staff has resulted in an improved and more efficient biologics service. Conclusion: Seventeen months in, the project has demonstrated that the association of biologic dose tapering with a gain share agreement can maintain the funding for extra resources. This addresses the pressures of an expanding biologics service and results in a more robust and efficient model.