Brown Bag Consults and Medication Therapy Management: Promoting Trust

Brown bag sessions and medication therapy management provide opportunities for pharmacists to personally connect with patients.

The Case

BK is a 69-year-old woman who has been coming to your pharmacy for the past 5 years. During this time, you have seen her become forgetful and nonadherent to various drug regimens due to her multiple diseases and medications. During your counseling session, you observe that BK is losing interest in her health. She seems negative, has gained weight, does not ask questions anymore, and appears stressed about the financial impact of her health care. You ask if she would be interested in participating in some additional counseling services. You explain what happens during a brown bag session and MTM consult, and tell BK you are interested in reeducating her and reviewing her medications. This will allow her to maximize their use and, ideally, inspire her to take more responsibility for her health. Adherence checks could also have a positive impact on both her finances and attitude. BK smiles and appreciates the opportunity to talk with you one-on-one. She eagerly schedules a time to meet with you after her doctor’s appointment later in the week, and she agrees to bring in all her medications and laboratory updates.

On reviewing BK’s medication profile at your pharmacy, you find the following:

• OTC aspirin 325 mg daily
• Metformin 500 mg twice daily
• Furosemide 40-mg tablet daily
• Enalapril 20-mg tablet daily
• Atorvastatin 80 mg daily

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

• OTC multivitamin daily
• OTC aspirin 81-mg tablets
• One Touch UltraMini meter and test strips
• Used insulin (insulin + insulin glargine) vials, expired 12/2016, unlabeled
• Various used and expired albuterol inhalers

After reviewing BK’s medications, you realize she would also benefit from an MTM session, so you schedule one. This will allow you to further communicate with her health care providers, review lab values, and evaluate her medical goals. At BK’s request, you will also offer more in-depth diabetes and asthma education. In the meantime, you gather more information and offer suggestions regarding her medications:

• BK admits that the inhalers were prescribed a few years ago by her physician. She uses them to help her breathe better when she is out walking and shopping; even light exercise leaves her short of breath, she tells you, but she has never been given an asthma diagnosis. You suggest that BK contact her current health care provider regarding the albuterol inhalers. You wonder if she might have asthma, which would require proper education and care. BK mentions that she snores a lot and has trouble sleeping, so you also want to talk with her provider about sleep apnea.
• BK’s furosemide, atorvastatin, and enalapril directions instruct her to take 1 tablet daily. When you look in the bottle, you notice that she has been cutting the tablets in half; her adherence also has been off in your electronic record. When you ask her about this, she says she stopped following directions due to some adverse effects she has been experiencing. She cuts her pills in half as a cost-saving measure and tells you that her provider is unaware of this. You notify the provider immediately after you note that BK’s blood pressure is greater than 130/80.
• You ask BK about the expired insulin vials and her blood sugar testing regimen. She explains that, without her provider’s knowledge, she stopped using insulin on a regular basis and does not test her blood sugar consistently. Her fear of needles and the cost of medications and supplies have hurt her adherence. You educate her on the importance of knowing her numbers and goals, and note that her glycated hemoglobin level is well above the normal range. You offer to make an appointment for BK and get her back on track with her medications, diet, and exercise. You suggest that her metformin dosage may need to increase (she still takes the starting dosage) and review general adverse effects of the medication. You also offer to practice her injection technique with her to help her gain confidence and comfort with needles.

Editor’s note: Cases are not based on actual patients.

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-inthe- kitchen.