Jill Drury, PharmD

The current health care environment makes it challenging for student pharmacists to find ways to shine. But the coronavirus disease 2019 (COVID-19) pandemic has given students the opportunity to assist pharmacists with new workflow issues and prioritize patient volume.

For many, this has led to prepandemic nostalgia, not just for what was once normal, but also for more simpler times when we could smile at customers from across the counter and make casual small talk with them without wearing a mask or worrying about the virus.

Yet, despite the new stress of managing safety and well-being in the pharmacy during the pandemic, it remains critical that we know our patients. Relationships are at the core of obtaining positive patient outcomes, and the pandemic has not erased patients’ chronic medical conditions or their need for treatment.

Student pharmacists are in a unique position to reestablish the definition of patient care within the pharmacy as we emerge from the pandemic. Offering services such as brown bag consults can demonstrate the importance of pharmacy services beyond dispensing.

A brown bag consult is when a patient gathers their current medications, including any OTC, mail order, specialty, and/ or herbal products, and figuratively puts them into a “brown bag.” The patient then reviews their medications with the pharmacist during the consult.

During a consult, student pharmacists can focus on supporting those who have chronic conditions, as they may be at higher risk for medical-related errors due to the quantity of different medications, a variety of health care providers, and potentially more than 1 pharmacy filling their prescriptions. When maintenance therapy needs adjustment, patients may additionally experience short- or long-term changes in their health.

Within the community, the student pharmacist is a provider with whom a patient may communicate on a consistent basis for follow-up care. Refill medication counseling is an excellent opportunity for students to identify vulnerable patients.

During refill medication counseling, students can ask open-ended questions to patients about possible concerns or changes, which makes it is easy to determine if further review by the student or pharmacist is necessary.

In this way, brown bag consults provide students and pharmacists a way to offer patients extended counseling concepts such as medication therapy management (MTM). These consults are an essential safety and educational tool to help the pharmacy measure and instill quality care within the health care system.

When conducting brown bag consults with patients, the student can identify potential problems or concerns that may require additional follow-up with the pharmacist or prescriber, or they can offer an MTM session to dis- cuss things further.

During the consult, the student pharmacist should first compare the medications in hand with those listed on a patient’s pharmacy profile. They should then check for duplication of therapy and identify any interactions. Medications need to be verified for the correct dosage strength and frequency.

The student also should identify if the patient has any outdated or discontinued medications. Providing an updated medication list to the patient at the end of the brown bag consult ensures the patient can share accurate information about their medications to any provider.

A brown bag consult is also a useful safety tool for patient adherence. Brown bag consults can show how well patients understand their conditions, their medications, associated health purpose, and any directions for taking the medication, as well as provide the pharmacist with insight into a patient’s lifestyle and quality of care.

Brown bag consults provide an opportunity to develop the patient-pharmacist relationship, which increases loyalty, trust, medical error prevention, and overall better individualized services. As value-based care initiatives grow throughout the health care landscape, brown bag consults are a proactive pharmacy-led contribution.

 is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.

Articles

Students Should Seize the Opportunity to Host Brown Bag Consults

Community pharmacists play a substantial role in helping patients maintain the health of their skin. From reducing the risk of sun exposure by recommending appropriate sunscreens to counseling patients on the use of OTC acne medications, pharmacists are often the first consulted health care professional when it relates to our body’s largest organ. Pharmacists also are on the front line of defense against skin cancer, as they are frequently consulted about potentially concerning skin conditions or lesions. It is important for community pharmacists to be aware of skin disorders and cancer risks so that they are able to help their patients by providing preventative and early-stage care. 

Brown bag sessions are a nice opportunity to not only review patient medications, but also the risks for developing preventable conditions. The pharmacy serves as both a chronic and preventative hub of care within the community. Pharmacists are ideally positioned to counsel patients about the importance of appropriate skin care. In addition, many medications can compromise the health of our body’s outer layer. Counseling patients on possible adverse effects that impact skin health can help patients prepare for serious or cosmetic impacts, such as rash, itching, redness, or discoloration. 

LP is a 57-year-old woman who is a relatively new customer to your pharmacy. Her life has been turned upside down by the pandemic. The pharmacy she used to go to changed their hours, making it harder for LP to consistently go there for care. LP also lost her job this past spring and does not have the same level of health insurance as she did in early 2020. She has become more conservative when it comes to preventative screenings and making appointments, as she does not have a lot of extra money to spend. 

When she was recently in your pharmacy to pick up a refill prescription, LP told you she had spent the summer trying to make the best of times by enjoying the outdoors and gardening. She told you that hiking and gardening are new for her and have caused her many scrapes, bumps, rashes, and itches. LP joked that she may be allergic to the outdoors. 

She also told you that as her summer tan started to fade, she noticed some dark spots that she never really saw before on her lower left leg and neck. You asked her about her sunscreen use, and LP admitted she never uses sunscreen. She thought getting a tan means having an attractive healthy glow. 

You counseled LP on her refill prescription and explained the concept of pharmacy brown bag and medication therapy management sessions. LP would be a great candidate to participate, as over the past few months you have noticed adherence issues and an increase in OTC medication usage. LP appreciated your attention and set up an appointment to meet with you tomorrow, when you have extra coverage, and liked the idea of hopefully saving money. 

To prepare for tomorrow’s session, you pull up LP’s pharmacy profile to compare it to what is in her brown bag: 

Levothyroxine 25 mcg, once daily every morning 

Lisinopril/hydrochlorothiazide 20/25 mg, daily 

Vitamin D3 1000 IU, twice daily as directed 

LP arrives the next day for your appointment. She empties her brown bag, and you notice these additional medications: 

OTC aspirin 81 mg enteric coated, once daily 

As you review the medications for accuracy, LP tells you that she has been feeling down, and she thinks her stress is impacting her health and mood. You ask her to explain further, and LP tells you that being out of work, the coronavirus disease 2019 pandemic, and not being able to embrace extended family has been making her feel depressed. She does not think her antidepressant is working, and she decided to only take it a few times a week. 

You calm LP down and explain to her that she still has people like you within the community to help. 

You explain that antidepressants do not just work every now and then, and stress the importance of taking her medication daily as prescribed. LP also admits to not taking her blood pressure medications as prescribed. She volunteers to start watching her blood pressure with a home cuff she has and to get in touch with her cardiologist after she tells you that she has 3 stents. 

Because LP has been spending a lot of time outdoors, you counsel her to take proper prevention from the sun’s rays and review some sunscreens you recommend. You also look at some of the dark moles that LP is worried about. You review the skin ABCDEs (asymmetry, border irregularity, color not uniform, diameter greater than 6 mm, and evolving size) and suggest LP follow up with her dermatologist because the moles do appear quite irregular. 

LP also tells you how she is going through a lot of OTC antihistamine treatments to treat various rashes and itchy skin. You suggest that she ask her dermatologist for a higher-strength hydrocortisone cream and to possibly conduct an allergy test. 

What other counseling tips and advice could you give LP as it relates to her medication list and cancer prevention? 

, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. 

Counseling patients on possible adverse effects that impact skin health can help patients prepare for serious or cosmetic impacts. 

Brown Bag Consult: Offering Preventative Cancer Care in the Community Pharmacy

Patients battling cancer should not be overlooked in any pharmacy setting. Many of these patients are in dire need of support, encouragement, and care coordination. They will endure a grueling process of coping with diagnosis, treatment, and, in cases of recovery, the fear of recurrence. All these stages will affect the patient both emotionally and physically. As the most accessible member of the health care team, the pharmacist can provide patients with cancer the information and support they need to get through what may be the most challenging time of their lives. Willingness to help at this crucial time demonstrates a caring and concern that patients likely will never forget. 

As the pharmacist, you scan the prescription list and review it against PD’s profile, noticing some changes. As you conduct your review, you see the concern and stress in PD’s face. You explain the concept of pharmacy brown bag and medication therapy management sessions and ask whether she would be interested in setting one up. PD is interested and informs you that she will bring in all her oral medications the following day. 

PD is looking forward to the opportunity to go over her entire history and current medication list. She has been feeling tired and depressed, on top of feeling anxious because of coronavirus disease 2019. It has delayed a scheduled surgery, kept her young kids out of school and at home, and has changed her work environment. The stress of balancing life is overwhelming, and she feels no one is listening to her needs. You sympathize and suggest PD visit about 2 in the afternoon, which is a slower time at your pharmacy. This will allow you the time to provide her with the best service and safest care. 

The next day, PD is waiting in your consultation area. Having done your homework, you have filled PD’s new prescriptions, opened her medication profile, and can now compare it with what is in her brown bag: 

Atorvastatin 10 mg daily (PD is splitting 20-mg tablets 

Ondansetron 4 mg as needed (filled at a competitor pharmacy) 

Alprazolam 0.5 mg as needed (filled at a competitor pharmacy) 

PD has been taking atorvastatin at a low dose and admits to not consistently taking her atenolol. She has not seen a cardiologist in years and relies on her oncologist and her internist to fill her medications. PD tells you she was given a diagnosis of a heart murmur back in college yet has never really done much about it or followed up, as was suggested. 

PD recently had fluctuations in cholesterol levels, but she claims her diet remains unchanged. In fact, her appetite is poor, and she tells you she feels as if she hardly eats. PD tells you she feels so bloated and uncomfortable after eating. In response, she avoids eating. PD also admits to feeling palpitations lately, when she is anxious. PD complains of leg cramps, and you suggest her renal function and cholesterol levels be reevaluated. PD also explains that she has not monitored her blood pressure. You take 3 readings, and her average blood pressure is above the recommended range. You suggest PD follow up with a cardiologist because of her history and worsening palpitations. 

PD complains of feeling tired and queasy all day. She tells you she has been taking more of her anxiety medication and feels as if she needs it to fall asleep, despite feeling so fatigued. PD is sleeping only 5 to 6 hours per night. You explain that a sleep aid may be more appropriate. You also acknowledge that this is a stressful time and suggest some nonpharmacological ways to reduce stress and improve sleep schedules: Avoid exercising at night, eat small meals, start a gratitude journal, practice yoga or stretching activities, read, and watch less television. PD appreciates your suggestions. You offer to contact her provider about the fatigue and nausea. 

The goal of a brown bag session is to discover discrepancies. Awareness can allow you to make a number of short- and long-term suggestions. Your advice may improve communication between PD and her providers, which may in turn improve PD’s quality of life and reduce her risk of needing doctor visits or hospital admissions. PD is willing to have you act as a community liaison between her and her providers. The first step is to follow up with PD’s providers. Make them aware of your brown bag session discoveries and the suggestions you have regarding PD’s care plan. 

Time will be your most challenging piece, and you will need to find a way to incorporate these clinical opportunities into your workflow. Loyalty and patient satisfaction are priceless and worth the energy to help. 

Many patients battling cancer are in dire need of support, encouragement, and care coordination.

Brown Bag Consult®: Chemotherapy Recovery With Heart Problems

MN is a 63-year-old woman who has multiple myeloma and frequents your health care system. Her diagnosis has been a huge emotional burden. MN continuously struggles to understand her treatment options and worries about what her diagnosis means for her quality of life and her family. 

Patients with multiple myeloma need resources, help, and hope every step of their journey. They will endure a grueling process of coping with diagnosis, treatment, and changes in treatment, as well as the fear of recurrence in cases of recovery. Each stage will affect the patient both emotionally and physically. 

As the most accessible member of the health care team, the pharmacist can provide patients with cancer with the information and support necessary to get through what might be the most challenging time of their lives. Willingness to help at this crucial time demonstrates a caring and concern that patients likely will never forget. 

The diagnosis threw a curveball at MN, a newly retired teacher with no family history of cancer. Her support system is limited because she is divorced and her children live out of state. MN relies on her pharmacy team and other members of the local community to help her through this rough patch. 

Originally, MN presented to the pharmacy complaining of extreme fatigue. The pharmacist on duty told MN to follow up with her primary care provider, given that the fatigue was out of the ordinary and not the result of a lifestyle change. 

Upon evaluation, MN received a diagnosis of symptomatic International Staging Symptom stage III high-risk multiple myeloma. MN’s laboratory results at the time included corrected calcium, greater than 11mg/dL; bone marrow, 20% plasma cells; b2 microglobulin, 5.7 mg/L; and deletion 17p, translocations in t(4;14). She had an ECOG status score of 0 and was eligible for autologous hematopoietic stem cell transplant (aHSCT). MN was prescribed bortezomib (Velcade), lenalidomide (Revlimid), and dexamethasone (VRd) as first-line treatment for induction and awaited transplant. 

Today MN returns for follow-up treatment after completing 3 cycles of therapy and aHSCT. She is complaining of worsening back pain, to the point that she cannot stand straight or walk well. She feels short of breath. MN also experiences neuropathy and says that she can no longer knit or write well. 

Laboratory values show that MN has normal liver and renal function. Post aHSCT, MN refused maintenance therapy and is now found to have recurrent disease, with an ECOG performance status of 1. She is rechallenged with VRd because guidelines recommend this option if relapse occurs less than 6 months from initial therapy. 

MN wonders why she is not getting the same multiple myeloma treatments that the people in her therapy group get. 

Why does she need both oral and injectable medications, whereas others get just oral drugs? Why do others seem to live normal lives but she struggles to perform basic functions? Are there other multiple myeloma treatments that cause less neuropathy? She explains that neuropathy prevented her from wanting to take maintenance therapy. 

MN is sad and possibly clinically depressed. She feels anxious all the time about the future, she says, and has a hard time being positive. You encourage her to share these feelings with her immediate care team. 

In this situation, as the pharmacist, you are not a primary decision maker on the care team, but you know of many nonpharmacologic ways you can help MN and recommendations you can make to her health care providers. You are MN’s most accessible resource. 

You set aside some time to talk with MN and discuss the different types of multiple myeloma treatments. She appreciates your patience as you explain things in a way she can understand. 

As you review MN’s as-needed medications, you realize she is overusing her prescribed anxiety and pain medications. You offer to follow up with her care team, address the issue, and help her develop a plan with more lasting effects. 

MN is not drinking water, so she is dehydrated, and she is not eating a balanced diet or getting any exercise. You help her find some recipes specifically for patients with cancer who have issues with taste and give her the name of a local dietitian. 

Although she has documented dyslipidemia and hypertension, MN says she no longer takes medications for those chronic conditions. You check her blood pressure, and it is high. You suggest that she follow up with her provider and get back on her prescribed medications, if necessary, after an evaluation. 

During your discussion on exercise, you learn that MN’s support group has a walking club and encourage her to participate. You assure her that when her pain is better managed, she should find it easier to move around and perform daily activities. In addition, you emphasize the importance of important bone health and deep vein thrombosis prevention. 

What else can you do for MN, and how will you follow up with her in a month, when she needs refills? Are her providers following National Comprehensive Network guidelines for her treatment? What supportive care could you recommend so that MN feels better managed? 

As the most accessible member of the health care team, the pharmacist can provide patients with cancer with the information and support necessary to get through what might be the most challenging time of their lives. 

Brown Bag Consult®: Patients With Multiple Myeloma Need Support Throughout Challenging Time

Affecting both male and female individuals, breast cancer is one of the most common types of cancer in the United States. The importance of early detection tools cannot be overemphasized, nor can proper self-screening and mammograms, which play a critical role in helping to prevent  deaths from breast cancer. 

However, eligible patients may not be screened for several reasons, very often because no one simply suggests a screening. Moreover, certain populations may not have health insurance or access to regular health care, may not be aware of the importance of screenings, or may not realize they are at risk.

As such, pharmacists should communicate the universal message that breast cancer screenings save lives. Often regarded as the most trusted and accessible health care professionals within the community, pharmacists have a unique opportunity to help patients by suggesting breast cancer screenings and follow-up care for those found to be at elevated risk. In addition, they can not only point patients to educational and financial resources but also help relieve anxiety related to the screening process or possible detection and diagnosis. 

Pharmacists can also refer patients to qualified health care providers for follow-up care, act as a direct resource, and serve as a prescriber-patient liaison. Finally, collaboration among pharmacists and other health-system health care providers is critical for the holistic care of the patient.

: A Case Study in Reducing Breast Cancer Risk in Your Patient Population 

Editor’s note: Case is not based on an actual patient.

EM is a 54-year-old woman who came into the pharmacy and mentioned that she found a lump after a recommended breast self-exam. She has no consistent primary care provider other than various nurse practitioners and specialists, whom she sees at the local clinic for other conditions. However, EM adds that she does not feel as if she has trusting relationships with any of those providers.

After some calls, you are able to provide EM with the name of a nearby primary care provider who in turn refers her to an oncologist and a surgeon. EM’s medical history is unremarkable, and she has no family history of cancer in first-degree relatives. A physical exam reveals that EM has a nonfixed mass in the left inferior breast without skin changes or nipple discharge and palpable lymphadenopathy in the left axilla. 

A mammogram confirms a left-sided, poorly defined spiculated mass. EM’s ultrasound shows a 5.3-cm solid mass and enlargement of 2 left axillary nodes with thickened cortex.

EM receives a core needle biopsy from the breast mass that confirms grade 3 invasive ductal carcinoma. Her new care team charts the following results:

Estrogen receptor negative; progesterone receptor negative; HER2 immunohistochemistry, 3+

Fine-needle aspiration of 1 left axillary lymph node is positive for carcinoma.

Because EM has been coming to your pharmacy for the past 10 years, you have a patient-pharmacist relationship with her. She stops in to follow up with you and share her HER2-positive breast cancer diagnosis. EM thanks you for encouraging her to be proactive about screenings. 

You know EM suffers from multiple other disease states and has always had trouble with medication adherence and management. You notice that she seems negative about her upcoming surgery and therapy. EM is worried about the financial implication of her disease state and mentions her stress and lack of support regarding her condition.

You ask EM whether she would be interested in participating in a brown bag consult and tell her that you are interested in reviewing all her medications and lifestyle choices before she undergoes cancer treatment. This will allow you both the opportunity to talk, share concerns, and ideally maximize EM’s medications. The consult may also lead to a positive financial impact and allow EM to feel as if she has a fresh start when it comes to her health.

What’s more, the opportunity to review EM’s medication list and adherence will let you make sure all her providers are aware of her new cancer diagnosis so that she will have a wider support system for any adverse effect management, medication holds, or dose adjustments. EM nods and appreciates the opportunity to talk with you in depth. 

Upon reviewing EM’s medication profile at your pharmacy, you find the following:

Polyethylene glycol—electrolytes solution, on hold

When EM comes in for her scheduled appointment, you notice the following additional medications in her brown bag:

Used insulin (insulin + insulin glargine) vials, expired July 2019, unlabeled

Adalimumab, 40 mg subcutaneous every other week, filled by mail-order specialty pharmacy

After reviewing EM’s medications, you realize she would benefit from a medication therapy management (MTM) session and schedule a follow-up appointment. An MTM session will allow you to further communicate with EM’s health care providers, obtain lab values, and further evaluate her medical goals, particularly those related to her breast cancer treatment and care plan.

EM has questions about HER2-positive breast disease. You briefly describe some of the various breast cancer types. EM explains that one of her friends with breast cancer just takes a pill, and EM asks whether she can do that as well. You explain that along with the various breast cancer types come different treatment options that are not interchangeable. 

EM is confused about targeted therapies. You discuss the difference between standard oncology therapies and targeted therapies, which offers EM some comfort. You review some of the treatment options her oncologist may discuss and offer to call her oncologist to obtain additional resources and educational support. EM will follow up with you after her surgery with her treatment care plan.

What treatment do you expect EM to receive for her HER2-positive breast cancer diagnosis?

What kind of supportive care will EM need?

EM is concerned about the financial impact of her treatment and other chronic conditions. How can you address cost when looking at her current and anticipated medications?

What hypothetical care plan would you offer EM at 3, 6, and 12 months?

, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.

Affecting both male and female individuals, breast cancer is one of the most common types of cancer in the United States. 

Brown Bag Consult®: Breast Cancer Risks and the Pharmacist’s Role

Researchers found that the efficacy of palbociclib plus letrozole in the treatment of hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer in the real-world setting was similar to the results from the PALOMA-2 trial.

 In addition, patients with a higher absolute neutrophil count (ANC) were found to have a higher risk for early disease progression.

The research was presented at the 2019 San Antonio Breast Cancer Symposium in San Antonio, Texas.

The ANC is the real number of white blood cells that are neutrophils, which help the body fight infection. Typically, having an ANC below 500 means there is a high risk of contracting an infection.

The combination of a cyclin-dependent kinase 4/6 (CDK4/6) inhibitor plus endocrine therapy has been shown to significantly improve the progression free survival (PFS) in patients with HR-positive, HER2-negative metastatic breast cancer. The study was conducted to evaluate the real-world benefit of palbociclib plus endocrine therapy as the first line treatment in HR-positive, HER2-negative metastatic breast cancer to correlate efficacy of the combination with neutropenia.

Participants were treated with palbociclib plus an endocrine therapy between January 1, 2015, and March 1, 2018, at Moffitt Cancer Center in Tampa, Florida. Using the Kaplan-Meier analysis, the PFS was determined and the predictive value of ANC and neutrophil-to-lymphocyte ratio (NLR) for PFS were examined using univariable and multivariable Cox models.

Out of 165 patients in the study, the median PFS was 24.19 months. For patients with bone metastasis only, the median PFS was not reached and for patients with non-bone-only metastasis, the median PFS was also 24.19 months.

Patients with a higher ANC are at high risk of early disease progression according to the researchers, but they did not find a significant association between the value of NLR and the risk of disease progression.

Real-world benefit of CDK4/6 inhibitor and endocrine therapy combination in metastatic breast cancer and correlation with neutropenia. Accessed Dec 2, 2019. 

https://plan.core-apps.com/sabcs2019/abstract/c384ee17f029c6ed91aef896ddbba228

NCI Dictionary of Cancer Terms: Absolute Neutrophil Count. Accessed Dec 3, 2019. 

https://www.cancer.gov/publications/dictionaries/cancer-terms/def/absolute-neutrophil-count

A study evaluated the real-world benefit of palbociclib plus endocrine therapy as a first-line treatment in HR-positive, HER2-negative metastatic breast cancer to correlate the efficacy of the combination with neutropenia.