A Change of Heart

Patients who suffer from chronic conditions may be at a higher risk for medical-related episodes and errors. These patients take a number of different medications, visit a variety of health care providers, and may use more than 1 pharmacy. Often, patients experience short- or long-term changes in their health that require adjustment of maintenance therapy.

Brown bag checkups are helpful not only to patients with chronic conditions but also for pharmacists in ensuring patient compliance. Brown bag checkups can show how well patients understand their conditions, their medications and their purpose, and the directions. These checkups provide insight into a patient’s lifestyle and quality of care. Brown bag sessions also provide the opportunity to develop the patient-pharmacist relationship to help guarantee loyalty, trust, medical error prevention, and overall better individualized services.

Hypertension is a major disease state and an independent risk factor for coronary artery disease, stroke, and renal failure. A number of guidelines should be reviewed and understood when a patient with hypertension is treated. It is important to discuss blood pressure goals, dietary habits, and medication regimens during counseling, brown bag checkups, and medication therapy management (MTM) sessions.

The Case

MF is a 55-year-old overweight female who is a relatively new customer at your pharmacy. She is a receptionist at a medical office and volunteers at the community center, where she organizes events. MF has become more aware of her weight issue and prescribed medications in light of a recent health scare involving a family member and because of numerous news stories regarding health care changes. During your counseling sessions, you notice her growing concern because she asks more questions about her heart, diet, and financial issues.

Today, MF stops in the pharmacy to pick up her late refill prescription for levothyroxine. You counsel her on the potential misuse and explain the purpose of a brown bag session. You tell her that due to her chronic disease states, you believe she would be an excellent candidate to participate in a review. You ask MF if she would be interested in bringing all of her medications to the pharmacy and reviewing them with you to discuss their proper use. MF is excited to have your attention. She explains that she feels confused trying to keep her medications straight and is embarrassed to ask questions of her colleagues at the medical office. MF admits that she cannot afford a hospitalization like her family member recently experienced. She schedules an appointment to meet with you tomorrow.

To prepare for tomorrow’s session, you pull up MF’s pharmacy profile so you are able to compare it with what is in her “brown bag”:

• Enalapril 20 mg, once daily

• Furosemide 20 mg, once daily, every morning

• Atorvastatin 40 mg, once daily, every evening

• Levothyroxine 25 mcg, once daily, every morning

• Esomeprazole 40 mg, once daily

• Paroxetine 20 mg, once daily

MF arrives the next day, with pen and paper ready to create a list. She empties her brown bag, and you notice the following additional medications:

• OTC aspirin 325 mg, once daily

• Calcium carbonate 1000 mg, once daily

• Adult multivitamin, once daily

• OTC omeprazole 20 mg, once daily

• OTC fish oil, 4 capsules daily

• Expired clopidogrel 75 mg, once daily; last filled at a competing pharmacy 2 years earlier

• Expired Crestor (rosuvastatin) samples

As you review the medications for accuracy, MF confides in you that, due to her limited budget, she is not always able to maintain compliance or loyalty to a single pharmacy or physician. She admits to no longer having a primary care provider and relies on the physicians she works with at the clinic and emergency departments to monitor her medication refills and health. MF cannot remember the last time she had laboratory work performed. She has been monitoring her blood pressure more frequently at the pharmacy, and has questions about her goals and diet.

You instruct her on how to take a proper, reliable blood pressure reading, and MF purchases a cuff for home use. You are able to take a more thorough medical history, and you discover that MF has 2 cardiac stents and is not actively seeing a cardiologist. MF is very interested in participating in the MTM session that you offered as a follow-up. How would you properly review MF’s medication profile, and what advice could you offer her during the brown bag checkup? MF needs to establish care with a provider in the community to help her effectively manage her conditions. How can you help her find proper medical personnel who will have a vested interest in her health?

Dr. Drury works as a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy from Midwestern University College of Pharmacy. Her blog, Compounding in the Kitchen, appears on www.PharmacyTimes.com.