Adherence Challenges for a Patient with Type 2 Diabetes Mellitus

Brown bag consults for patients living with chronic diseases do not have to be time-consuming or even scheduled. Consults can simply be offered to select patients who you feel need follow-up care after a counseling session. Offering to review a patient’s medications can give you an opportunity to personally connect with your patients. Reviewing patients’ prescription and OTC medications, herbal supplements, and vitamins can give pharmacists the opportunity to educate patients and assess their safety and quality of care.

The Case

Patients with type 2 diabetes mellitus (T2DM) can benefit from brown bag sessions and medication therapy management (MTM). A pharmacist’s involvement may help patients understand their therapy and may increase regimen adherence. For patients with T2DM, pharmacist intervention can also help with appropriate prescribing of medications, including angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers; keeping vaccinations up-to-date; and using aspirin therapy.

TM is a 74-year-old female who has been coming to your pharmacy for the past 10 years. Over this time, you have seen her become forgetful and nonadherent to various drug regimens due to her multiple disease states. In your last counseling session with TM, you noticed that she does not have as much interest in her health as she had in the past. She seems negative about her therapy, has gained weight, does not ask questions anymore, and seems stressed about the financial impact of her disease states.

You ask TM if she would be interested in participating in a brown bag consult. You explain what it entails and tell TM that you are interested in reviewing her medications and reeducating her to help her maximize their use. This may also have a positive financial impact for TM. Ideally, you will be able to improve her overall attitude and health. TM says she appreciates the opportunity to talk with you in depth, one on one. She schedules a time with you after her doctor’s appointment later in the week, and she agrees to bring all of her medications and laboratory updates.

When reviewing TM’s medication profile, you find the following:

• OTC aspirin 325 mg, daily
• Metformin 1000 mg, twice daily
• Pioglitazone 45 mg, daily
• Furosemide 40-mg tablet, daily
• Enalapril 20-mg tablet, daily
• Atorvastatin 40-mg tablet, daily

When TM comes in for her appointment, you notice 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 12/2013, unlabeled
• Various used and expired albuterol inhalers

After reviewing these medications, you realize TM would benefit from an MTM session, so you schedule a follow-up appointment. An MTM session will allow you to further communicate with TM’s health care providers, review lab values, and further evaluate TM’s medical goals. A session will also allow you to offer in-depth T2DM and asthma education, as requested by TM. In the meantime, you have some questions about her medications and suggestions for her:

• TM admits that the inhalers are prescribed for her husband, but she uses them to help her breathe better when she is walking and shopping. You offer to contact her prescriber regarding the inhalers. You wonder whether TM could be diagnosed with asthma. If she is, she may need proper education and care.
• TM’s furosemide, atorvastatin, and enalapril directions instruct her to take 1 tablet daily. You notice, however, that TM has been cutting the tablets in half and that her adherence has been off according to your computer system. When you ask about this, she admits that she has not been following the directions. She cuts her pills in half as a cost-saving measure and says that her provider is unaware of this. You notify TM’s health care provider immediately after you note that TM’s blood pressure is well above 140/90 mm Hg.
• You ask TM about her expired insulin vials and her blood sugar testing regimen. She explains that she stopped using insulin on a regular basis without her health care provider’s knowledge and she does not test her blood sugar on a regular basis. The cost of medications and supplies has hurt her adherence. You educate her on the importance of knowing her numbers and goals. You offer to help her make an appointment with her health care provider and get her back on track with her medication, diet, and exercise. You also offer TM an opportunity to practice her injection technique to help her get more comfortable with needles.

What else would you suggest to TM before her MTM session?

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.