Education Before Medication

A patient with type 2 diabetes has inadequate blood glucose control.

Planning a brown bag event for your patient population does not have to be a time-consuming scheduled event. It can simply be offered every day to select patients who you feel need follow-up care after a counseling session. Offering to review a patient’s medications can give the pharmacist an opportunity to personally connect with their patients by serving as the trusted health professional within the community. By reviewing prescription medications along with OTC medications, herbal supplements, and vitamins, pharmacists have the opportunity to educate and assess safety and quality of care.

Brown Bag Consult: Type 2 Diabetes

Patients with chronic disease states such as diabetes can benefit from suggested brown bag sessions and medication therapy management (MTM). A pharmacist’s involvement may aid with a patient’s understanding of therapy and help increase regimen compliance. Pharmacist intervention can also help with appropriate prescribing of medications, including ACE inhibitors and ARBs and the use of aspirin therapy in patients with diabetes.

PS is a 64-year-old woman who has been coming to your pharmacy for the past 5 years. Over this time, you have seen her become noncompliant with various drug regimens due to her multiple disease states. You noticed in your last counseling session that PS does not have as much positive energy as she used to have in the past. She seems negative about her therapy and is worried about the financial impact of her disease states. You ask PS if she would be interested in participating in a brown bag session. You explain what happens during a brown bag consult and tell PS you are interested in reviewing and re-educating her on her medications. This will allow her to maximize their use and possibly have a positive financial impact. PS smiles and appreciates the opportunity to talk with you in depth, one-on-one. She schedules a time with you tomorrow to bring in all of her medications.

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

• OTC aspirin 325 mg daily
• Metformin 1000 mg twice daily
• Pioglitazone 45 mg daily
• Furosemide 80-mg tablet daily
• Enalapril 10-mg tablet daily

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

• Flunisolide nasal spray 1 spray into each nostril once daily (filled at competitor pharmacy 3 months ago)
• OTC multivitamin daily
• Used insulin (insulin + insulin glargine) vials, expired 12/2010, unlabeled
• Various rosiglitazone 4-mg sample packets, expired 1/2011, unlabeled

After reviewing the medications in PS’s possession, you realize PS would benefit from an MTM session and you schedule a follow-up appointment. An MTM session will allow you to further communicate with PS’s health care providers, obtain lab values, and further evaluate PS’s medical goals, especially related to her diabetes. An MTM session will also give you the opportunity to offer in-depth diabetes education, as requested by PS.

In the meantime, during this brown bag consult, you have some questions surrounding her medications and some suggestions:

1) PS is taking OTC aspirin 325 mg daily. You suggest she switch to an 81-mg enteric-coated tablet if she is taking it for cardiovascular prophylaxis.

2) You suggest to PS that you contact her prescriber regarding her flunisolide nasal spray. You wonder if an inhaled corticosteroid is the best agent for her allergic rhinitis and are also wondering if the directions are correct.

3) PS’s furosemide and enalapril directions instruct her to take 1 tablet daily. Yet you notice when you look in the bottle that PS has been cutting the tablets in half and her compliance has been off in your computer system. You ask her about this and she tells you she was not following directions. She cuts her pills in half as a cost-saving measure and tells you her provider is unaware of her manipulation. You notify the provider immediately after you note her BP is well above 130/80 mm Hg.

4) You ask PS about her expired insulin vials and her blood sugar testing regimen. You also ask her about her expired rosiglitazone samples. She explains that she stopped using insulin on a regular basis without her provider’s knowledge and does not test her blood sugar on a regular basis. Cost of medications and supplies plus her fear of needles has hurt her compliance.

You educate PS on the importance of knowing her numbers and goals. You offer to help make her an appointment and get her back on track with her medication, diet, and exercise. You also offer PS an opportunity to practice her injection technique so she gets more comfortable with needles. PS is instructed that the pioglitazone she refills at your pharmacy is similar to her expired rosiglitazone samples. You instruct her that she should not be using those in combination and offer to dispose of her expired medications for her to alleviate confusion.

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 in 2007. In addition to her current work, she is a blogger for PharmacyTimes.com and a speaker for Abbott Pharmaceuticals.