Battle of the Bulge

Although patients frequently visit multiple physician specialists for various conditions, weight and nutritional concerns are often overlooked. Pharmacists can be instrumental in identifying and helping patients with weight management issues and eating disorders. As community health care providers, pharmacists see patients on a regular basis. Knowing their patients, their lifestyles, and their medical conditions allows pharmacists to proactively identify concerns and holistically care for their community.

Obesity is a growing worldwide concern and is associated with increased morbidity and mortality. Regardless of who or what is responsible for the rising incidence of obesity, it has increased the risk for heart disease, high blood pressure, type 2 diabetes mellitus, and abnormal cholesterol levels. In addition to these conditions, obesity can stress joints, weaken the immune system, and lead to anxiety and depression. Pharmacists have an excellent opportunity to provide unbiased weight management consultation and brown bag sessions. If more follow-up and goalsetting are needed, medication therapy management (MTM) sessions can be effective for informing and caring for patients. These opportunities for care can help avoid unnecessary medical costs related to weight-related issues and improve the quality of life and the dietary habits of obese individuals.

Obesity and Binge Eating

BM is a 35-year-old woman who has come to your pharmacy for the past 2 years to fill her prescriptions. BM is obese. You estimate that she weighs 245 lb and is 5 ft 3 in tall. You know from past counseling sessions that BM is very concerned about her weight, feels ashamed about her eating habits and appearance, and often feels out of control. She has a history of knee pain, headaches, attention-deficit/hyperactivity disorders, and depression.

When BM comes to the counter to collect her prescriptions, you ask if she would be interested in participating in a brown bag session. You explain what it entails and tell BM that you are interested in reviewing her medications and re-educating her as needed. BM appreciates the opportunity to talk with you in depth, one on one. You schedule a time to meet again the next day.

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

• Escitalopram 10 mg daily

• Sumatriptan 100 mg as directed as needed (refill overdue)

• Loestrin Fe daily

• Triamcinolone cream 1% apply to affected areas as needed

• Ibuprofen 800 mg every 6 hours as needed (usually filled 3 to 4 days early)

• Lorcaserin 10 mg twice daily (on hold in computer system; never filled)

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

• OTC ibuprofen 200-mg tablets

• OTC acetaminophen 500-mg tablets

• OTC omeprazole 20-mg capsules

• OTC multivitamin daily

• Orlistat 120 mg 3 times daily (filled at competitor pharmacy; refill overdue)

After reviewing the medications in BM’s possession, you realize BM might benefit from an MTM session, so you schedule a follow-up appointment. An MTM session will allow you to further communicate with BM’s health care providers, obtain lab values, and further evaluate BM’s medical status and goals. In the meantime, you have some questions and suggestions about her medications:

1. BM tells you how she is taking her OTC acetaminophen and ibuprofen. She has been using too much in response to uncontrolled headaches and joint pain. Because BM is exceeding the daily limits, you suggest that she discontinue use of these products, and you offer to speak to her providers regarding therapeutic alternatives and possible lab tests to identify toxicity. BM’s use of acetaminophen and ibuprofen may be the cause of her recent onset of stomach upset, which she is managing with OTC omeprazole. You counsel BM about the side effects of her medications and say that you will follow up with her.

2. You suggest to BM that you contact her prescribers regarding her weight management issues and medications. You ask BM to set some goals for your MTM session regarding her weight and eating habits. BM confesses that she often binge eats when she is alone, and sometimes doesn’t even realize she is eating too much until it is too late and she has consumed an entire container of ice cream. She does not have any compensatory behaviors, yet she feels very depressed and ashamed of her habits. You would like to help her share her concerns with her provider, who may want her to see a specialist and nutritionist. Weight loss medications that have been prescribed to BM do not seem to be the ideal therapeutic choice. They are causing undesirable side effects, leading to adherence and quality-of-life issues. The cost of these medications also concerns BM. She is also taking medication to treat depression. You suggest that BM join a local support group that could help her with her weight, shame, and self-esteem.

3. BM is very nonadherent in regard to taking her multivitamin. You briefly counsel her on nutrition and ideal vitamin intake. You also show BM how to read a nutritional food label. BM appreciates your concern and time. She is looking forward to losing weight and learning how to control her binges.

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.