A Checkup at the Pharmacy, Part II: How Brown Bagging Can Bring Clarity

SEPTEMBER 27, 2017
Jill Drury, PharmD
Gastrointestinal conditions make up a big part of health care in the United States. Many visits to health care providers, hospitals, and community outpatient care centers are made for digestive system symptoms such as indigestion, diarrhea, and constipation. Gastrointestinal disorders can be challenging to properly diagnose and treat. The diagnostic evaluations performed on patients can involve a variety of invasive procedures that some are not always willing to undergo. For many, just the topic itself can be uncomfortable and can hinder seeking professional care. Patients also may choose to bypass the health care system and use one of the myriad OTC medications available. Many do not seek help until the symptoms become unbearable, and by then, complications may have occurred. Understanding the basic characteristics of some gastrointestinal issues, the challenges behind patient care, and available treatment options is essential to providing the best comprehensive patient care in the pharmacy.

Pharmacists can offer patients brown bag consults, which can be essential safety and educational tools to measure and ensure quality care. By asking patients to gather their current medications, including OTC, mail-order, specialty, and herbal products for review, pharmacists can ensure up-to-date and appropriate care.

Pharmacists are key providers in the continuum of care, consistently helping to identify potential problems and concerns that may require follow-up with prescribers or a medication therapy management (MTM) session. Brown bag consults can do the following:
  • Show how well patients understand their conditions and medications
  • Provide insight into a patient’s lifestyle and quality of care
  • Develop the patient–pharmacist relationship to help guarantee patient loyalty and trust and to help ensure medical error prevention and better individualized services. Incorporating brown bag consults into your workflow is essential.
THE CASE
JD is a 33-year-old female who is a returning customer to the pharmacy. She is a self-proclaimed foodie and is always talking about the new hot spots in town during your counseling sessions and on social media. JD loves to experiment with new foods, flavors, and recipes. Her energy and passion for life is astounding. Last month, JD stopped into the pharmacy to pick up an early-refill prescription for her alprazolam. You noticed that she was not her usually energetic self, and when you ask how she was doing, she did not give you her typical thumbs-up. You counseled her on the alprazolam and explained the concept behind brown bag sessions you frequently offer patients. You told JD that because she has had some past compliance issues, and is on multiple medications, that you thought she would be an ideal candidate to participate in a brief review. JD was interested in brought in all her medications for you to look over. JD was happy to have your attention and help with her medications and care.

JD follows up to take a deeper dive into her medication profile. Based on some of the recommendations that you made during your brown bag session, you want to know if JD has made any progress toward better health and is feeling better. To prepare for the complementary MTM session you are offering, you pull up JD’s pharmacy profile again from last month:
  • Albuterol inhaler, 1 to 2 puffs every 4 to 6 hours, as needed
  • Alprazolam, 0.5 mg, 1 tablet every day, as needed
  • Fluticasone propionate, 250 mcg/salmeterol 50 mcg Diskus, twice daily *
  • Norgestimate/estradiol tablets (Ortho Tri-Cyclen Lo), once daily
  • Dicyclomine, 20 mg, 1 tablet, as needed, up to 3 times daily
  • Ondansetron, 4 mg oral disintegrating tablet, 1 tablet under the tongue, as needed for nausea
  • Ibuprofen, 600 mg every 6 to 8 hours, as needed, for cramps/stomach pains**
**Prescribed by ob-gyn physician

When JD arrived for the appointment, you noticed these additional medications in her brown bag:
  • OTC famotidine, 20 mg, twice daily
  • OTC ranitidine, 150 mg, twice daily
  • Calcium carbonate, 500 mg, as needed
  • Adult multivitamin with iron, once daily
  • OTC omeprazole, 20 mg, once daily
  • OTC brand Advil (ibuprofen), 200 mg, as needed
  • OTC vitamin D, 1000 units, daily
During your brown bag session, you warned JD of duplicate medications. You were very concerned about safety, toxicity, and adverse effects. You were also worried that she was treating the symptoms and not an underlying undiagnosed condition. You advised JD to follow up with a primary-care provider and give the provider the comprehensive medication list that you gave her. JD mentioned that she didn’t have a regular provider and that she often cannot pronounce drug names. She gets confused over “what is what” when talking to providers. The list of provider recommendations, drug names, and indications should help JD confidently discuss what she is consistently taking for her symptoms. 

Today, JD tells you how lucky she was to get a timely appointment with a provider you recommended, thanks to your help. JD never had a regular provider and expresses that she felt very comfortable with the new physician who listened and empathized when she discussed her issues. JD was never “officially” diagnosed with asthma. Her new provider performed pulmonary function tests, which showed she does not have asthma. The provider will re-test if symptoms re-occur with stress, exercise, or seasonal changes. JD is happy and grateful to save the extra money every month by eliminating medications that she does not need. In fact, she can’t really remember why she was placed on inhalers in the first place. The provider referred JD to a gastroenterologist to review her symptoms and discomfort. JD’s gastroenterologist revised her medication profile and ran lab tests and scans. JD tells you that her quality of life is still not what it was a few months ago, yet the situation has improved. JD has also revised her diet and is eating more gluten-sensitive and low-fat alternatives after talking to a nutritionist on staff at the gastroenterology office. 

JD provides you copies of her lab results and mentions to you how her white blood cell count and liver enzymes were slightly elevated. The provider told her that she has many gallstones, and a scan showed that she may need surgery soon. In the meantime, JD is hoping that some of the diet modifications she is making help with inflammation flare-up, uncomfortable bloating, constipation, and diarrhea.

JD shares her new medication profile with you so you can update your records:
  • Norgestimate/estradiol tablets (Ortho Tri-Cyclen Lo), once daily
  • Dicyclomine, 20 mg, 1 tablet, as needed, up to 3 times daily
  • Ondansetron, 4 mg ODT, 1 tablet under the tongue, as needed for nausea
  • OTC ranitidine, 150 mg, twice daily, as needed
  • Adult multivitamin with probiotic, once daily
  • OTC vitamin D, 1000 units, daily
What else do you want to review with JD? Can you provide additional help at this point? How will you follow up with JD next month if necessary?
 
Dr. Drury works as a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy degree from Midwestern University College of Pharmacy. Her blog, Compounding in the Kitchen, an innovative amalgam of pharmacy and cooking, appears on PharmacyTimes.com/ blogs/compounding-in-the-kitchen.


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