Gastrointestinal Issues: Part 1

Gastrointestinal conditions make up a big part of health care in the United States, but they can be challenging to properly diagnose and treat. The diagnostic evaluations performed on patients can involve invasive procedures that some are not always willing to undergo. Patients also may choose to bypass the health care system and use one of the myriad OTC medications available. Many do not seek help until the symptoms become unbearable, and by then, complications may have occurred.

Pharmacists can offer patients brown-bag consults, which can be essential safety and educational tools to measure and ensure quality care. By asking patients to gather their current medications, including OTC, mail-order, specialty, and herbal products for review, pharmacists can ensure up-to-date and appropriate care. Pharmacists are key providers in the continuum of care, consistently helping to identify potential problems and concerns that may require follow-up with prescribers or a medication therapy management (MTM) session. Brown-bag consults can do the following:

• Show how well patients understand their conditions and medications
• Provide insight into a patient’s lifestyle and quality of care
• Develop the patient—pharmacist relationship to help guarantee patient loyalty and trust and to help ensure medical error prevention and better individualized services. Incorporating brown-bag consults into your workflow is essential.

THE CASE

JD is a 33-year-old female who is a returning customer to the pharmacy and a self-proclaimed foodie. Today, JD stops into the pharmacy to pick up her early-refill prescription for her alprazolam. When you ask how she is doing, she doesn’t give you her typical thumbs-up. You counsel her on the alprazolam and quickly explain the concept behind a brown-bag session. You tell her that because she has had some past compliance issues and is on multiple medications, you think she would be an ideal candidate to participate in a brief review. You ask JD if she would be interested in bringing in all her medications and going over them with you for proper use, and she sets up an appointment to meet with you tomorrow.

In preparation, you pull up JD’s pharmacy profile so you can compare it with what is in her brown bag:

• Albuterol inhaler, 1 to 2 puffs every 4 to 6 hours, as needed
• Alprazolam, 0.5 mg, 1 tablet every day, as needed
• Fluticasone propionate, 250 mcg/salmeterol 50 mcg Diskus, twice daily *
• Norgestimate/estradiol tablets (Ortho Tri-Cyclen Lo), once daily*
• Dicyclomine, 20 mg, 1 tablet, as needed, up to 3 times daily
• Ondansetron, 4 mg oral disintegrating tablet, 1 tablet under the tongue, as needed for nausea
• Ibuprofen, 600 mg every 6 to 8 hours, as needed, for cramps/stomach pains**

*Prescribed by ob-gyn physician

JD arrives the next day for the appointment, and you notice these additional medications in her brown bag:

• OTC famotidine, 20 mg, twice daily
• OTC ranitidine, 150 mg, twice daily
• Calcium carbonate, 500 mg, as needed
• Adult multivitamin with iron, once daily
• OTC omeprazole, 20 mg, once daily
• OTC brand Advil (ibuprofen), 200 mg, as needed
• OTC vitamin D, 1000 units, daily

As you review the medications for accuracy, JD tells you that she has some insecurity about her gastrointestinal issues and doesn’t always seek medical advice. You ask about her symptoms, and JD says that the medications provide only temporary relief. The alprazolam helps calm her down and often relieves the pain. Her quality of life is not what it was a few months ago, yet JD says that she prefers to make treatment decisions on her own. She says that she just wants quick relief and comfort so that she can eat and drink whatever she wants like a “normal” person. You and JD discuss her diet and your concerns. JD is on many OTC medications and has not disclosed these to her providers. JD has never been officially diagnosed with a gastrointestinal issue, but she needs to be referred and tested for proper treatment. JD does not have a regular primary care physician but does accept a list of providers you recommend. Because of your brown-bag session, JD is very interested in participating in the MTM session you offered.

How would you counsel JD? How can you prepare for her MTM session? 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-in-the-kitchen.