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Medication Counselling 23

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Medication Counselling 23
By Leya Luhar   .   July 31, 2024 .   Last reviewed:   24/09/24 .    




Summary

 

In this scenario, the student is expected to counsel a pataient who is about to start methotrexate for their condition. Their role is to answer the patient’s questions appropriately and provide them with any important information. 

Please ensure that this scenario and mark scheme aligns with the most up-to-date guidelines from the UK NICE and the BNF when using it for your OSCE assessment. 

You will need a student pharmacist and an actor for this OSCE station.

Revision Topics
Be aware, this may reveal any answers!

Methotrexate  

Rheumatoid Arthritis  

Student Instructions

You are the pharmacist. You have been asked to counsel a patient who has recently been initiated on methotrexate for rheumatoid arthritis. The patient is a 47-year-old female who has recently been diagnosed with rheumatoid arthritis and has been prescribed methotrexate weekly injections. 

To do  

  1. Provide the patient with detailed information about their medication, addressing any questions, concerns and queries they may have regarding their treatment plan and condition. 

You have 10 minutes.
You have access to the BNF.

Actor AI 🤖 (Beta)
Actor Instructions

You are Ayna Hertford (Eye-na, Hurt-ford).

Opening statement: "I've just been prescribed methotrexate injections for my rheumatoid arthritis, and I have some questions about it." 

Patient information: 

Provide this information when prompted.

  • Name: Ayna Hertford 

  • Age: 47 

  • Prescription: 

    • Methotrexate 7.5 mg once weekly via subcutaneous injection 

  • Past medical history: 

    • Rheumatoid arthritis (recently diagnosed) 

    • High blood pressure 

  • Medication History: 

    • Lisinopril 10 mg once daily for high blood pressure 

    • Ibuprofen 400 mg as needed for pain 

  • Allergies:

    • “None” 

  • Symptoms: 

    • "I have joint pain and swelling, particularly in my hands and knees." 

    • "I experience morning stiffness that lasts more than 30 minutes." 

    • "The doctor said the blood tests showed 'inflammation.'" 

 

  • Lifestyle factors: 

    • "I'm a non-smoker." 

    • "I drink alcohol socially, about 1-2 glasses of wine per week." 

    • "I work as a teacher." 

    • "I live with my husband and two teenage children." 

    • "I have a moderate exercise routine that includes walking and yoga." 

    • "I'm postmenopausal." 

 

You have not started taking the medication yet. You do not know much about methotrexate other than it is for your rheumatoid arthritis, so you wanted to clarify some questions first. 

 

Questions: 

  1. “Does someone do the injections for me, or do I do them myself?”
  2. “I’ve been told to collect some pills to take while I’m on the injections - what are these?” If the student says folic acid: “yes, that rings a bell.”
  3. “Any side effects I need to be aware of?”
  4. “I’m going on holiday to Mexico for a month, what will I do about my injections?”

 

If the student does not know – ask them if there is someone that would know.

 

Mark Scheme

Introduction 
0 / 2
Introduce yourself as the pharmacist with an appropriate greeting
+1
Confirms patient details: Name and age 
+1
Medical History
0 / 6
Confirms past medical history
+1
Confirms medication history including dose, frequency, indication, including any over-the-counter products and herbal remedies 
+1
Confirms new medication dose, form, indication, AND frequency
+1
Confirms allergies
+1
Confirms symptoms and any investigation results
+1
Confirms the patient is postmenopausal
+1
Hormones are also thought to play an important role in the development of rheumatoid arthritis. It affects more women than men and commonly comes on during periods of hormonal change for women, such as after giving birth or onset of menopause. As per National Rheumatoid Arthritis Society, 2025.
Patient Safety
0 / 1
Should identify the patient is taking ibuprofen, recognise the potential interaction with methotrexate, and recommend alternative pain relief or advise suitable monitoring
+1
As per BNF - There is a severe interaction. Ibuprofen is predicted to increase the risk of toxicity when given with Methotrexate (particularly high-dose). Manufacturer advises monitor. Monitoring examples include monitoring for signs of methotrexate toxicity, renal impairment, consequent increased gastrointestinal and haematological toxicity.
Question 1 
0 / 3
Does someone do the injections for me, or do I do them myself?
You will usually go to your GP surgery or a hospital outpatient clinic once a week to have your injection. 
+1
Alternatively, you may get a pre-filled injection pen or syringe for you to use at home. Your doctor or nurse will show you how to use this. 
+1
You may need to check with the airline about the protocol for bringing injections with you. Show them the dispensing label at the airport if necessary
+1
Question 2 
0 / 3
I have been told to collect some pills to take while I am on the injections - what are these?
This is folic acid
+1
Folic acid helps reduce some of the side effects of methotrexate
+1
This should be taken once a week (but not on the same day as methotrexate injections)
+1
Question 3 
0 / 6
Any side effects I need to be aware of? (Maximum 1 mark awarded):
Loss of appetite
Nausea and vomiting
Abdominal pain or indigestion
Diarrhoea
Headache
Tiredness
Hair loss
Skin sensitivity
Skin may become sensitive to sunlight, so advise the patient to stay out of the bright sun, use SPF30 or above and avoid using sun beds or sun lamps
If any of the side effects above are bothersome, speak to a doctor or pharmacist on ways to reduce the side effects.
+1
Allow discretionary marks if side effect stated is in the BNF.
States or discusses the following red flag side effects (Maximum 3 marks) :
Yellowing of skin or eyes, abdominal pain
This may indicate liver toxicity.
New cough, chest pain, shortness of breath
This may indicate pneumonitis.
 Swollen hands or feet, difficulty urinating
This may indicate renal impairment or another underlying condition.
Fever, chills, muscle aches, sore throat 
This may indicate an infection.
Bleeding in gums, urine, vomit, bruising
This may indicate agranulocytosis.
Call 111 and seek urgent medical attention if these develop.
+1
Question 4 
0 / 3
I’m going on holiday for a month, what will I do about my injections?
We will discuss this with your doctor
+1
It may be possible to have a small supply of tablets prescribed for you to use instead during your holiday, or to take your injections if you have the correct storage facilities
+1
Reminder to use/wear sun protection
+1
Communication and knowledge 
0 / 6
Uses appropriate language for the person and situation
+1
Uses volume, tone, pace and emphasis appropriately, and gives time to ask questions
+1
Knowledge and understanding of the topic is apparent
+1
The conversation is structured and flows well
+1
Concludes well, by asking if the patient has any further questions
+1
  The student did not say anything that could harm the patient  
+1
This includes but is not limited to, providing incorrect information or medication, misdiagnosing conditions, neglecting to inquire about allergies, making incorrect referrals, or failing to act on red-flag symptoms.
Time Management
0 / 1
Completed the scenario in time and achieved 70% of marks
+1

 

Any criteria marked in red must be met to pass this station.  




red flag Red Flags missed: 5

Total Score
0/31
Skills
professionalism 0/2
information gathering 0/7
patient safety 0/25
knowledge 0/26
patient education 0/24
problem solving 0/6
decision making 0/3
communication 0/4
patient-centred care 0/2
Time Management 0/1


Please login to save your score.
Referral Criteria

Referral Criteria for Methotrexate  

 

Refer to Accident and Emergency (A&E) if: 

  • Lips or tongue become swollen, difficulty breathing or struggling to swallow:  Signs of allergic reaction. 

  

Refer for an Urgent GP Appointment if: 

  • Oral ulcers present: Sign of bone marrow suppression, increasing likelihood of infection. 

  • sore throat:  Sign of bone marrow suppression, increasing likelihood of infection. 

  • Unexplained rash: This could indicate a severe allergic reaction or drug-induced skin conditions, such as Stevens-Johnson syndrome or toxic epidermal necrolysis. 

  • abnormal bruising: could be a sign of thrombocytopenia (a low platelet count) or bone marrow suppression. 

  • Persistent diarrhoea: a sign of gastrointestinal toxicity, which could lead to severe dehydration and electrolyte imbalances. 

  • Yellowing of skin or eyes, abdominal pain: May indicate liver toxicity. 

  • Swollen hands or feet, and difficulty urinating: May indicate renal impairment. 

  • Bleeding in gums, urine, vomit, bruising: Possible indicator for agranulocytosis. 

  • New or increasing dyspnoea or dry cough: may indicate methotrexate-induced pneumonitis, a potentially serious lung condition. 

References

  • Electronic Medicines Compendium (EMC). (2023).Methotrexate 2.5mg Tablets - Summary of Product Characteristics (SmPC). [online] Available at: https://www.medicines.org.uk/emc/product/511/smpc#gref

  • National Rheumatoid Arthritis Society (NRAS) (n.d.) Possible causes and risk factors. Available at: https://nras.org.uk/resource/possible-causes-and-risk-factors/ (Accessed: 12 January 2025).

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