Gastrointestinal Issues

Gastrointestinal (GI) conditions are a major reason for health care use in the United States. Many visits are made to health care providers, hospitals, and community outpatient care centers regarding digestive system symptoms such as heartburn, acid reflux, diarrhea, and constipation. GI disorders can be challenging to properly diagnose and treat. The associated diagnostic evaluations include various invasive procedures that some patients cannot afford or are not willing to undergo.

For many patients, even discussing GI discomfort can be uncomfortable and may prevent them from seeking professional care. Because of this, patients may bypass the health care system via self-diagnosis and self-treatment with the many OTC medications for GI problems. Many patients do not seek medical help until their symptoms become unbearable and complications have occurred. Understanding the basic characteristics of GI issues, the related challenges regarding patient care, and the available treatment options is essential to providing the best comprehensive patient care in the pharmacy.

THE CASE

TM is a 37-year-old man who is an infrequent customer at your pharmacy. He is an architect and self-proclaimed foodie. During counseling sessions, TM talks about the new culinary hotspots in town and his social media pages, where he posts pictures and reviews of food, bars, and restaurants. He loves to experiment with new flavors, and his energy and passion for life are astounding.

Today, TM stops by the pharmacy to pick up his early refill prescription for his epinephrine injection and 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 high 5. He seems reluctant to discuss the issue, so you do not press. You counsel TM on his refills and quickly explain brown bag and medication therapy management (MTM) sessions. You are trying to do more comprehensive medication reviews and stress the value of the services the pharmacy offers.

You tell TM that because he suffers from asthma, has had past adherence issues, and is taking multiple medications, he would be an ideal candidate for a brief medication review. You ask TM if he would be interested in bringing in all his medications and reviewing them with you for proper use. TM says he is not feeling well and would be happy to participate. He makes an appointment to meet with you.

To prepare for tomorrow’s session, you access TM’s pharmacy profile to compare it with what is in his “brown bag”:

• Albuterol inhaler: 1 to 2 puffs every 4 to 6 hours, as needed
• EpiPen (epinephrine injection): inject as directed during reactions
• Fluticasone propionate 250 mcg/salmeterol 50 mcg Diskus, twice daily
• Ibuprofen 600 mg every 6 to 8 hours, as needed, for cramps/stomach pains

TM arrives for the appointment and empties his brown bag. You notice the following 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 Advil (ibuprofen) 200 mg, as needed

As you review the medications for accuracy, TM tells you about his growing number of food allergies and his stomach discomfort. He tells you, in confidence, that with his limited budget and insecurity about his GI symptoms, he is not always able or willing to seek medical advice. You ask him about his symptoms, and he claims the medications seem to provide only temporary relief. His quality of life is not what it was a few months ago. However, TM says he prefers to browse the pharmacy aisles in private and make treatment decisions on his own. To make his decisions, he uses the Internet and what he hears from doctors on television.

You ask TM about his goals, and he says he just wants quick relief and comfort so he can eat and drink whatever he wants like a normal person. You and TM briefly discuss his diet and your concerns. TM is taking many OTC medications and has not notified his health care provider. He seems to be spending a significant amount of money on these medications despite his limited budget.

TM has never received an official diagnosis of a GI condition, but it is clear he needs to be referred for proper evaluation and treatment. You question the use of his epinephrine injection. TM does not have a consistent primary care physician, so he accepts a list of providers you recommend for follow-up consultation. Because of this brown bag session, TM is very interested in participating in the MTM session you offered to further investigate his issues and concerns. Stay tuned...

Dr. Drury works as 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-inthe- kitchen. Read and enjoy!