Specialty Care in the Community: Following Up With Another Brown Bag Session

Brown bag counseling sessions do not have to be time-consuming or burdensome. They may be offered to select patients whom you have identified as potential beneficiaries of extra counseling. By offering to review a patient’s medications, the pharmacist is able to better connect with the patient and to develop the interpersonal skills essential for a community pharmacist. Ideally, the brown bag session will allow you to educate the patient and assess any safety and quality- of-care concerns. Plus, it’s an excellent means of fostering the pharmacist—patient bond.

Brown Bag Consult

Patients suffering from chronic autoimmune disease states (eg, rheumatoid arthritis) are particularly amenable to brown bag sessions and medication therapy management (MTM). A short brown bag session can help a patient understand his or her treatment and can promote regimen compliance. The involvement of the pharmacist provides an additional source of information and a safety and compliance check.

LB—a 48-year-old male—is a 3-year customer. Over that time, LB has been diagnosed with multiple disease states, including a recent diagnosis of rheumatoid arthritis (RA). In your last counseling session, you noted that LB appeared more depressed and lacked his usual positive energy. He appeared frustrated with his therapy and the financial impact of his disease states. You ask LB if he would be interested in participating in a brown bag session. You explain the brown bag consult and let him know you are interested in reviewing his medications with him. As you explain, the brown bag consult will allow LB to maximize his prescriptions, ensure safety, and possibly reduce his financial burden. LB appreciates your advice and offer, so he schedules a time to meet with you. LB will bring in all of his medications, which you will review with him in detail.

Upon reviewing LB’s medication profile, you discover the following:

• OTC aspirin 325 mg daily
• Atorvastatin 20 mg daily
• Ibuprofen 600 mg every 12 hours as needed
• Celecoxib 200 mg every 12 hours
• Hydroxychloroquine 400 mg daily

When LB comes in for his scheduled appointment, you find the following additional medications in his brown bag:

• Flunisolide nasal spray, 1 spray into each nostril once daily; filled at a competitor pharmacy 3 months ago
• OTC multivitamin daily
• OTC ibuprofen 200-mg tablets
• OTC acetaminophen 500-mg tablets
• Prednisone 5 mg as directed; last filled more than 1 year ago at a competitor pharmacy
• Unfilled written prescription for adalimumab subcutaneously 40 mg every 2 weeks; dated 3 months ago

After reviewing the medications in LB’s possession, you realize LB would benefit from an MTM session, and you schedule a follow-up appointment. An MTM session will allow you to further communicate with LB’s health care providers, obtain lab values, and further evaluate LB’s medical goals, especially those relating to his RA. An MTM session will also provide you the opportunity to offer in-depth disease state education, as requested by LB. In the meantime, you have some questions and suggestions surrounding his medications:

• LB is taking OTC aspirin 325 mg daily. You suggest that he switch either to an 81-mg enteric-coated tablet (if he is taking it for cardiovascular prophylaxis) or to as-needed use (if he is using it as an anti-inflammatory). LB doesn’t know who told him to start taking aspirin, so you will clarify the reason for use with his providers.
• You suggest to LB that you contact his prescriber regarding his flunisolide nasal spray. You wonder if an inhaled corticosteroid is the best agent for his allergic rhinitis, and you are also wondering if the directions are correct.
• LB admits that he has missed numerous physical therapy sessions and has even postponed recommended surgery for his RA. He also expresses his concerns about his unfilled adalimumab prescription, including the cost of the medication and the need for it to be injected. He doesn’t understand how specialty pharmacies differ from community pharmacies and how they may better assist with his financial and disease state concerns. You offer to contact his provider and his preferred specialty pharmacy for assistance. This may impact LB’s compliance, medication profile, and overall quality of life.
• LB may be taking too much ibuprofen through his combined OTC and prescription use. You counsel him on the daily recommended use and the potential side effects of excessive use. What else would you suggest to LB before his MTM session?