Gastrointestinal Issues: The Follow-Up

TM is a patient at your pharmacy who participated in a brown bag session. When you initially counseled him, you explained brown bag and medication therapy management (MTM) sessions. In your pharmacy practice, you are actively trying to perform more comprehensive medication reviews and stress to patients the value of services you offer.

Because TM suffers from asthma, is prone to nonadherence, and is taking multiple medications, you determined he was an ideal candidate for a brief review. TM was very interested in your offer and brought in his medications. After discussing TM’s treatment goals and evaluating the medications in his “brown bag,” you had a few concerns.

You documented his medications:

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

During the brown bag session, TM focused on his new-onset stomach discomfort, not his chronic asthma. He said he has a limited budget and is embarrassed about his gastrointestinal (GI) symptoms, which he feels are disrupting his life and getting out of control. You and TM briefly discussed his diet and his many OTC medications. You wanted to disclose these to his providers because TM was never advised to take these medications, nor was he given an official diagnosis of a GI condition. You questioned the appropriate use of his epinephrine injection because he admitted to having a growing number of food allergies. You uncovered that TM does not have a consistent primary care physician, so you provided some recommendations.

A month later, TM arrived for your scheduled counseling update. Because TM does not qualify for a billable MTM service, you treat today’s session as a comprehensive follow-up to your brown bag review. Now that TM has a local primary care provider, you have been communicating with the physician and her team. The provider gave TM orders for general lab work and pulmonary function testing, which had not been performed in many years. TM was also referred to a GI specialist to address his many symptoms.

TM’s nurse addressed your first suggestion regarding his medications. As a result, his OTC omeprazole, calcium carbonate, and famotidine were discontinued. Due to the severity of some of TM’s symptoms, which included nausea, vomiting, and diarrhea, his specialty care team did further testing and discovered TM has a severe gluten allergy. Despite the temporary financial setback caused by this allergy, TM agrees that his new lifestyle and diet will improve his quality of life. TM says that because the underlying issue to his discomfort has been discovered, he will no longer need to spend money on OTC medications to treat his GI symptoms. TM also says he has not had to use his epinephrine injection, which he acknowledges should be reserved for true allergic emergencies, and his headaches have subsided.

You were also concerned about TM’s asthma control and ibuprofen use. TM’s nurse agreed that TM should stick to using only OTC acetaminophen or ibuprofen for pain control, when needed. Therefore, the nurse discontinued the ibuprofen prescription on file at your pharmacy. Regarding TM’s asthma, the nurse and the physician both think it may be seasonal. Before writing prescriptions, they gave TM some sample medications to see if they provided relief.

TM brings his new inhalers to your appointment and says he was never trained how to use inhalers. Even after reviewing the instructions and making multiple attempts to use the inhalers, he does not feel like “the medicine ever goes in.” Therefore, he often empties his inhalers faster than he should, contributing to his nonadherence issues. TM admits to never throwing away old inhalers, saying he has many that he randomly uses. You explain the importance of expiration dates and safety, and encourage him to throw out old inhalers or return them to the pharmacy. You also review TM’s various new inhalers with him and demonstrate proper use, as well as explain the role of short-acting inhalers versus long-acting inhalers to help with asthma control. TM understands your review and says he will focus on his asthma and its triggers now that his GI symptoms have started to subside.

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!