Metastatic Breast Cancer

In past columns, I have explained the many counseling opportunities for community pharmacists. Pharmacists working in hospital pharmacies have similar counseling opportunities. For example, medication reconciliation is a form of brown bagging and medication therapy management (MTM). Both can be used to advance communication and prevent errors. As with an MTM session, medication reconciliation helps ensure that a patient’s medications are accurate and safe.

By relying on medication reconciliation, a hospital pharmacist can prevent errors that occur when a patient’s medications include prescription drugs, OTC drugs, herbal products, and dietary supplements. The process allows for checking omissions, duplications, dosing errors, adherence, and drug interactions. In all, the services provided by the inpatient or outpatient pharmacy team enhance communication between the provider and the patient.

Patients battling cancer should not be overlooked in the community pharmacy setting. These patients are in dire need of help and hope. They will endure a grueling process of coping with their diagnosis and treatment and, in cases of recovery, the fear of recurrence. All of these stages will impact the patient emotionally and physically.

As the most accessible members of the health care team, pharmacists can provide cancer patients with the information and support they need to get through what might be the most challenging time of their lives. Willingness to help at this crucial time demonstrates care and concern that patients will likely never forget.

The Case

DT is a loyal customer of your pharmacy and has become a regular patient at the local community hospital and clinic. DT was diagnosed with metastatic breast cancer about 2 years ago and is facing many ups and downs in her treatment. DT gives you a new list of her medications and current laboratory data. She explains that she just left the oncology clinic and that these are her most up-to-date documents.

As the pharmacist, you notice the medication reconciliation performed by the pharmacist working in the oncology clinic. You review it against DT’s profile at your pharmacy and notice several changes. As you conduct your review, you see the concern and confusion in DT’s face. You explain the concept of pharmacy brown bag and MTM sessions and ask if she would be interested.

DT is relieved and informs you that she will bring in all her medications the next day. She is looking forward to the opportunity to review her entire history and current medication list. She has been confused and mildly depressed on top of feeling anxious due to her medical condition. You suggest that DT arrive at 3:00 pm, which is a slower time in your pharmacy. This will allow you to provide her with the best service and care.

The next day, DT is waiting in your consultation area. You have filled her new prescriptions, opened her medication profile, and obtained access to her hospital laboratory data and medication reconciliation. You compare the information you found against the contents of DT’s brown bag:

• Enteric-coated aspirin 81 mg daily
• Atorvastatin 20 mg daily
• Niacin dietary supplement
• OTC omeprazole 20 mg daily
• Ondansetron 4 mg as needed
• Lorazepam 0.5 mg as needed
• OTC acetaminophen 500 mg as needed
• Everolimus 10 mg daily
• Exemestane 25 mg daily
• Magic mouthwash as directed
• OTC loperamide as needed

Your review of DT’s medication reconciliation and hospital discharge papers revealed the following:

• Atorvastatin 40 mg daily
• Niaspan 500 mg daily at bedtime
• Enteric-coated aspirin 81 mg daily
• Atenolol 25 mg daily
• Ibuprofen 600 mg twice daily
• Everolimus 10 mg daily
• Exemestane 25 mg daily

The goal of a brown bag session is to discover discrepancies. Awareness can allow you to make a number of short- and long-term suggestions. Your advice may improve communication between DT and her multiple providers. This in turn may improve DT’s quality of life and reduce her risk for hospital readmissions.

DT is willing to have you act as a community liaison between her and her providers. The first step is to follow up with DT’s providers. Make them aware of your brown bag session discoveries and the suggestions you have for DT’s plan of care. You will need to find ways of incorporating these clinical opportunities into the work flow.

What general suggestions do you have after reviewing DT’s brown bag medications? What laboratory data might have helped you when you reviewed DT’s medications?

DT definitely needs more counseling and follow-up care in the community pharmacy. Considering time restrictions, how can you help ensure that DT stays on this new track toward a better quality of life?

Follow-up on DT

In this month’s brown bag consult, we tried to help DT, who was recently discharged from a hospital and has a diagnosis of metastatic breast cancer. After you reviewed her medications, what general suggestions did you have? What laboratory data might have helped you when you reviewed the medications?

DT definitely needs more counseling and follow-up care in the community pharmacy. Considering the time restrictions of a brown bag session, how can you help ensure that DT stays on this new track toward better health?

Here are some ideas:

1. Remind DT to visit your pharmacy during nonpeak hours or when you have overlap coverage. This will allow you to give greater attention to DT and her case.

2. Remind DT to always carry a current medication list in her purse. This will help health care providers in all settings to be “on the same page.”

3. Encourage DT to fill all her medications at 1 pharmacy so it can help act as her “hub” of care. DT has a number of comorbidities. If she is interested, offer to provide follow-up education and evaluate her understanding during an extended counseling session.

4. You notice some discrepancies during your brown bag session. Follow up and let the appropriate providers know the following:

• DT has been taking atorvastatin at various doses. She recently had a spike in her cholesterol levels, but she claims that her diet hasn’t changed. After discovering that hyperlipidemia is a possible side effect of everolimus, you may suggest that DT have her renal function and cholesterol levels reevaluated.
• DT tells you that her generic Niaspan co-pay is too high, so instead she started taking a niacin dietary supplement without telling anyone. She says she heard from a media source that it “is the same thing” as generic Niaspan. Notify her that the 2 products are not equal. Suggest that DT have her lipid panel reevaluated.
• DT is taking a dosage of everolimus that may need to be titrated downward based on side effects. Suggest that DT go to her primary care provider for routine blood work and evaluation of her side effects (ie, diarrhea and mouth sores). Offer DT advice on supportive care related to her breast cancer diagnosis. This can include advice on nutrition, nausea/vomiting, drowsiness, depression, pain, and anxiety.
• DT tells you she forgot about her blood pressure medication. You obtain 3 blood pressure readings showing that DT’s blood pressure is above the recommended range.

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, appears on www.PharmacyTimes.com.