Digestive Health

As a whole, patients diagnosed with gastrointestinal (GI) conditions are the source of a large portion of the health care services used in the United States each year. GI disorders can be challenging to properly diagnose and treat. Many visits are made to health care providers, hospitals, and community outpatient care centers for digestive system symptoms such as heartburn, diarrhea, or constipation. The diagnostic evaluations performed on patients can involve a variety of invasive procedures that some are not always willing to undergo. For many, even discussing the topic of GI distress can be uncomfortable, which ultimately may impact their decision to seek professional care.

Patients also have the option to bypass the health care system as a whole and self-diagnose and self-treat with the surplus of OTC medications currently available. Many do not seek help until their symptoms become unbearable, however, by which time complications may have occurred. Understanding the basic characteristics of some GI issues, knowing the challenges to patient care, and reviewing available treatment options are essential to providing the most comprehensive patient care.

The Case

PD is a 35-year-old man who is a returning customer to your pharmacy. He is a hard-working realtor by day and avid runner by night. Today, PD stops in the pharmacy to pick up his early refill prescription for his albuterol inhaler. You notice he is not his usual energetic self, and when you ask how he is doing, he does not give you his typical smile. He seems embarrassed about the issue, so you do not press.

You counsel him on the early albuterol refill and quickly explain the concept behind a brown bag session. You tell him that since he suffers from asthma and past adherence issues and is on a handful of medications, you think he would be an ideal candidate to participate in a brief review. You ask PD if he would be interested in bringing in all of his medications and going over them with you for proper use. PD is happy to have your attention. He has heard about reviews like the one you are suggesting from his insurance plan. He sets up an appointment to meet with you tomorrow.

To prepare for tomorrow’s session, you pull up PD’s pharmacy profile so you are able to compare it with his “brown bag”:

• Albuterol inhaler 1 to 2 puffs every 4 to 6 hours as needed (prescribed by a pulmonologist)
• Fluticasone propionate 250 mcg/salmeterol 50 mcg diskus twice daily (prescribed by a pulmonologist)
• Montelukast 10 mg once daily (prescribed by a pulmonologist)
• Ibuprofen 600 mg every 6 to 8 hours as needed for pain (prescribed by an orthopedic physician)
• Naproxen 500 mg every 8 hours as needed (prescribed by an urgent care nurse practitioner)

PD arrives the next day for your appointment. He empties his brown bag and you notice these additional medications:

• OTC famotidine 20 mg twice daily
• Calcium carbonate 500 mg as needed
• Adult multivitamin with iron once daily
• OTC omeprazole 20 mg once daily
• OTC ibuprofen 200 mg as needed
• OTC cetirizine 10 mg once daily

As you review the medications for accuracy, PD tells you that he has been feeling insecure about some GI symptoms he has been consistently experiencing over the past month. Flatulence, constipation, heartburn, and cramping stomach pain are some of the symptoms he mentions. You ask him about those symptoms, and PD claims the OTC medications he is buying seem to provide only temporary relief; his quality of life is not what it was a few months ago. PD expresses that he prefers to browse the pharmacy aisles in private and make treatment decisions on his own when it comes to this sensitive topic.

To make his decisions, he uses the Internet and what he hears from doctors on television. You ask PD about his goals, and he tells you he just wants quick relief and comfort so he can eat and drink whatever he wants like a “normal” person and run comfortably again. You and PD briefly discuss his diet and your concerns. PD is on OTC medications that he has not disclosed to all providers. Moreover, he seems to be spending a significant amount of money on medications that are not providing long-term relief. It is also important to note that although PD has never been officially diagnosed with a GI issue, it is clear he needs to be referred for proper evaluation. PD does not have a regular primary care physician anymore, but does accept a list of providers you recommend for consult. Because of your brown bag session, PD is very interested in using you as a resource for advice in the future.

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, an innovative amalgam of pharmacy and cooking, appears on www.PharmacyTimes .com/blogs/compounding-in-the-kitchen. Read, and enjoy!