Counsel Patients About the Symptoms of Celiac Disease

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

Brown bag consults can be essential educational and safety 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 guarantee appropriate and up-to-date care.

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

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

Offering to review medications one-on-one can give pharmacists the opportunity to connect with patients by serving as trusted medical professionals in the community. Brown bag sessions do not have to be time-consuming scheduled events. These consultations can be offered anytime a pharmacist thinks that a patient requires follow-up care after a typical counseling session.

KP is a relatively new patient who moved to the area for a teaching job. She is not feeling like herself, and when you counsel her, you explain the concept behind brown bag and MTM sessions. The pharmacy is actively trying to do more comprehensive medication reviews and stress the value behind services it offers. Because KP has asthma and says she has adherence issues, you believe she would be a candidate for a brief review and ask whether she is interested. She appreciates the offer and brings in her medications to be checked.

Here is what is in her brown bag:

• Albuterol inhaler, 1 to 2 puffs every 4 to 6 hours, as needed, expired January 2019
• Alprazolam, 0.5 mg, once daily, as needed
• Calcium carbonate, 500 mg, twice daily
• EpiPen (epinephrine injection), inject as directed during reaction, refilled 3 times within 6 months
• Fluoxetine, 20 mg daily
• Fluticasone propionate, 250-μg/salmeterol 50-μg diskus, twice daily
• Lo Loestrin, 24 Fe, once daily
• Montelukast, 10 mg, daily
• OTC ibuprofen, 600 mg, every 6 to 8 hours, as needed for cramps or stomach pain
• OTC famotidine, 20 mg, twice daily
• OTC omeprazole, 20 mg, twice daily

After discussing KP’s treatment goals and evaluating the medications in her brown bag, you have some concerns. During the session, KP tells you about her extreme gastrointestinal discomfort. She also says she is embarrassed about the symptoms she is experiencing. She says feeling as if she always has to run to the bathroom is no fun, and she feels ashamed. KP adds that she takes OTC medications around the clock for her discomfort, especially after meals, when she feels the worst. You briefly discuss KP’s diet and suggest some healthy modifications. You encourage her to contact her primary care provider (PCP) to ensure nothing serious is going on because the symptoms are newer and worsening. KP has never received a formal diagnosis of a gastrointestinal issue, hence the recommendation for some follow-up.

You also question the appropriate use of her epinephrine injection, as she admitted to a growing number of food allergies. KP says she has not seen a clinician for her allergies or asthma since she moved. A different climate and local foods can possibly be a factor in her reactions. KP says she thinks an app would help remind her to take her medications and monitor her symptoms. She downloads one to assist with adherence, and you promise to follow up.

KP returns for the follow-up and asks to speak with you. She says that she made an appointment with her PCP, per your recommendation. KP is no longer taking any of the unnecessary medications for gastrointestinal issues. Her provider sent her for a scan and discovered that she needed her gallbladder removed. The provider also ran some tests and thinks KP may have celiac disease. She is feeling better and is on the road to recovery. KP has no family history of autoimmune, gallbladder, or gastrointestinal issues, so these health issues came as a surprise. She thanks you for your help and tells you that without your suggestions, she does not know what might have happened. KP says that the app she downloaded to help with adherence is working. You also notice that she is on time for her refills this month.

What else can you suggest to KP about her possible diagnosed celiac disease and her diet? Has she been monitoring her asthma? How would you prepare for next month’s visit?

Jill Drury, PharmD, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.