A 39 year old female is at your pharmacy window waiting to pick up the following medications after her rheumatology clinic visit:

Methotrexate 10 mg po once daily

Adalimumab 40 mg sc every other week

Ibuprofen 400 mg po Q6H prn

a) What information would you obtain prior to dispensing these medications? (4 marks)

b) You are able to obtain some laboratory data for this patient. Based on the information below, would you recommend providing hepatitis B prophylaxis? If yes, please state the reasons and the regimen. (5 marks)

Chemistry:

Na: 136 mmol/L

K: 3.8 mmol/L

Serum creatinine: 60 micro mol/L

Alanine aminotransferase ALT: 123 IU/L

Alkaline phosphatase (ALP): 105 IU/L

Haematology:

Haemoglobin (Hgb): 11.8 g/dL

White blood cell (WBC): 5.0 x 10⁹ /L

Platelet (Plt): 190 x 10⁹ /L

Virology:

Hepatitis B surface antigen (HBsAg): positive

Anti-hepatitis C virus (HCV): negative

Anti-human immunodeficiency virus (HIV): negative

c) What pertinent monitoring parameters for the prophylactic regimen would you suggest? (3 marks)

d) Which other medications may carry a moderate to high risk of hepatitis B reactivation? (3 marks)