Brown Bag Consult®: Chemotherapy Recovery With Heart Problems

Patients 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 the information and support they need to get through what may be the most challenging time of their lives. Willingness to help at this crucial time demonstrates a caring and concern that patients likely will never forget.

As the pharmacist, you scan the prescription list and review it against PD’s profile, noticing some changes. As you conduct your review, you see the concern and stress in PD’s face. You explain the concept of pharmacy brown bag and medication therapy management sessions and ask whether she would be interested in setting one up. PD is interested and informs you that she will bring in all her oral medications the following day.

PD is looking forward to the opportunity to go over her entire history and current medication list. She has been feeling tired and depressed, on top of feeling anxious because of coronavirus disease 2019. It has delayed a scheduled surgery, kept her young kids out of school and at home, and has changed her work environment. The stress of balancing life is overwhelming, and she feels no one is listening to her needs. You sympathize and suggest PD visit about 2 in the afternoon, which is a slower time at your pharmacy. This will allow you the time to provide her with the best service and safest care.

The next day, PD is waiting in your consultation area. Having done your homework, you have filled PD’s new prescriptions, opened her medication profile, and can now compare it with what is in her brown bag:

• Atorvastatin 10 mg daily (PD is splitting 20-mg tablets
• Ondansetron 4 mg as needed (filled at a competitor pharmacy)
• Alprazolam 0.5 mg as needed (filled at a competitor pharmacy)
• OTC acetaminophen 500 mg as needed
• OTC ibuprofen 200 mg as needed
• OTC loperamide as needed

PD’s pharmacy profile:

• Atorvastatin 20 mg daily
• Atenolol 25 mg daily
• Ibuprofen 600 mg twice daily
• Letrozole 2.5 mg daily
• Olaparib 300 mg twice daily

PD has been taking atorvastatin at a low dose and admits to not consistently taking her atenolol. She has not seen a cardiologist in years and relies on her oncologist and her internist to fill her medications. PD tells you she was given a diagnosis of a heart murmur back in college yet has never really done much about it or followed up, as was suggested.

PD recently had fluctuations in cholesterol levels, but she claims her diet remains unchanged. In fact, her appetite is poor, and she tells you she feels as if she hardly eats. PD tells you she feels so bloated and uncomfortable after eating. In response, she avoids eating. PD also admits to feeling palpitations lately, when she is anxious. PD complains of leg cramps, and you suggest her renal function and cholesterol levels be reevaluated. PD also explains that she has not monitored her blood pressure. You take 3 readings, and her average blood pressure is above the recommended range. You suggest PD follow up with a cardiologist because of her history and worsening palpitations.

PD complains of feeling tired and queasy all day. She tells you she has been taking more of her anxiety medication and feels as if she needs it to fall asleep, despite feeling so fatigued. PD is sleeping only 5 to 6 hours per night. You explain that a sleep aid may be more appropriate. You also acknowledge that this is a stressful time and suggest some nonpharmacological ways to reduce stress and improve sleep schedules: Avoid exercising at night, eat small meals, start a gratitude journal, practice yoga or stretching activities, read, and watch less television. PD appreciates your suggestions. You offer to contact her provider about the fatigue and nausea.

The goal of a brown bag session is to discover discrepancies. Awareness can allow you to make a number of short- and long-term suggestions. Your advice may improve communication between PD and her providers, which may in turn improve PD’s quality of life and reduce her risk of needing doctor visits or hospital admissions. PD is willing to have you act as a community liaison between her and her providers. The first step is to follow up with PD’s providers. Make them aware of your brown bag session discoveries and the suggestions you have regarding PD’s care plan.

Time will be your most challenging piece, and you will need to find a way to incorporate these clinical opportunities into your workflow. Loyalty and patient satisfaction are priceless and worth the energy to help.

JILL DRURY, PHARMD, BCOP, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.