Battling Cancer: How Brown Bagging Can Bring Clarity

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

Patients who are 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 with the information and support they need to get through what might be the most challenging time of their lives. A willingness to help at this crucial time demonstrates caring and concern that patients likely will never forget.

One option to help patients: brown bag consults, which can be essential safety and educational tools to measure and ensure quality care. By asking patients to bring in all their current medications, including OTC, mail order, specialty, and herbal products, pharmacists can ensure up-to-date and appropriate care.

Pharmacists are key providers in the continuum of care, consistently helping to identify potential problems and concerns that may require follow-up with prescribers or a medication therapy session (MTM). It is essential that a pharmacist’s workflow allow for brown bag consults, which can do the following:

• Show how well patients understand their conditions and medications
• Provide insight into a patient’s lifestyle and quality of care
• Develop the patient—pharmacist relationship to help forge patient loyalty and trust, prevent medical errors, and create better individualized service

The Case

TR is a 65-year-old customer of the pharmacy who has become a regular patient at the local community hospital and clinic. She recently received a diagnosis of metastatic breast cancer after being cancer-free for 10 years. TR faces many ups and downs with her various treatment options. She presents a new list of medications and laboratory data and says that she just left the oncology clinic and that these are her most up-to-date documents. You look through the papers and notice the medication reconciliation performed by an inpatient pharmacist. You review it against TR’s profile at the pharmacy and notice some changes. As you conduct the review, you see the concern, stress, and confusion on her face. You explain the concept of pharmacy brown bag and MTM sessions and ask TR if she would be interested. She is interested and says that she will bring in all her oral medications the following day. TR is looking forward to the opportunity to go over her entire history and medication list. She has been feeling confused and mildly depressed on top of anxious because of her diagnosis. TR’s youngest son is getting married in the spring, and she wants nothing more than to be happy and healthy. You suggest that she visit at about 2 pm, which is a slower time at the pharmacy. This will allow you to provide TR the best service and care.

The next day, she is waiting in the consultation area. Having done your homework, you have filled TR’s new prescriptions, opened her medication profile, and gained access to the inpatient laboratory data and medication reconciliation. This is what you found when you pulled up her pharmacy profile, after reviewing medication reconciliation and hospital discharge papers:

• aspirin, enteric coated (EC) 81 mg daily
• atenolol 25 mg daily
• atorvastatin 20 mg daily
• ibuprofen 600 mg twice daily
• niacin 500 mg daily at bedtime
• tamoxifen 20 mg daily

You compare what is in TR’s brown bag with your information:

• aspirin, EC 81 mg daily
• atorvastatin 40 mg daily
• letrozole 2.5 mg daily
• lorazepam 1 mg as needed
• ondansetron 4 mg as needed
• OTC acetaminophen 500 mg as needed
• OTC loperamide as needed
• OTC omeprazole 40 mg daily

The goal of a brown bag session is the discovery of discrepancies. Awareness can allow you to make a number of short- and long-term suggestions. Your advice may improve communication between TR and her providers. This may improve her overall quality of life and reduce her risk of hospital readmissions. TR is willing to have you act as a community liaison between her and her providers. The first step is to follow up with her providers. Make them aware of your brown-bag session discoveries and the suggestions that you have regarding TR’s plan of care. Time will be your biggest challenge, and you will need to find a way to incorporate these clinical opportunities into a workflow. Loyalty and patient satisfaction are priceless and worth the energy to help TR.

What suggestions do you have after reviewing her brown bag medications? What laboratory data might have helped when you reviewed TR’s medications? Are there guidelines that could help understand her treatment plan? TR needs more counseling and follow-up care at the pharmacy. Considering time restrictions, how can you help ensure that she does not fall off the track that you have helped her get on toward an ideal quality of life?

Here are a few ideas for TR’s follow-up care:

1. Remind her to visit your pharmacy during off-peak hours or when you have overlap coverage. This will allow you to give greater attention to detail and focus more on TR herself.

2. Advise her to always carry a current medication list in her purse or on her phone. This way, when a health care provider in any setting asks TR what medications she is taking, everyone will be on the same page, and there will be less stress with trying to remember.

3. Encourage her to fill all her medications at 1 pharmacy when possible so that the pharmacy team can act as her “hub” of care. TR has a number of comorbidities, so if she is interested, offer to provide follow-up education and evaluate her understanding during an extended counseling session. 4. Follow up with the appropriate providers, because you noticed discrepancies during the brown bag session. Let them know that:

• TR has been taking atorvastatin at various doses and admits to not consistently taking her niacin and atenolol. She has not seen a cardiologist in a few years and relies on her oncologist and internist to fill her medications. TR recently had fluctuations in cholesterol levels, yet she claims that her diet remains unchanged. You may suggest that her renal function and cholesterol levels be reevaluated after she complains of leg cramps. TR also explains that she has not monitored her blood pressure. You take readings, and find that her blood pressure is above the recommended range. You suggest that TR follow up with a cardiologist because of her history.
• She is unsure whether she should continue taking her tamoxifen or take it in combination with her letrozole. TR feels tired and remembers the oncologist telling her about another new medication that she needed to obtain from a specialty pharmacy. She is worried about cost, adverse effects, and losing her hair. You help TR follow up with her oncologist so that she can better understand her new drug regimen and how much it will cost.
• Because of the pain in her legs and general malaise, she has been taking ibuprofen so that she can move around. TR complains of stomachaches and says that she has been popping OTC omeprazole daily. You explain that this is not ideal and follow-up care is urgently needed for her leg cramps and stomach pain, which could be an ulcer.
• TR is overweight, and she expresses how she would like to live a healthier lifestyle. She has also been a smoker for 20-plus years and, despite not being ready to quit, asks for more information on medications to help her kick the habit.

Jill Drury, PharmD, is 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-in- the-kitchen.