Take the Brown Bag Challenge: Gluten Intolerance

Food allergies have seemed to be on the rise in recent years. Even a minuscule amount of an allergy-inducing food may trigger the signs and symptoms of a digestive issue. Wheat allergy is one of the most common food allergies. It can occur even in the absence of a family history. Although sometimes misdiagnosed as celiac disease, wheat allergy is different in that it generates an allergy-causing antibody to proteins found in wheat. In contrast, celiac disease is an abnormal immune system response in the small intestine caused by the gluten in wheat. Gluten is the insoluble protein constituent of wheat. It is obtained from flour by washing out the soluble starch. For some people, eating gluten results in potentially life-threatening malabsorption.

A gluten-free diet helps relieve the problems associated with gluten allergy. However, enjoying gluten-free meals demands some motivation and an acquired taste. Anyone purchasing food for a person with a gluten allergy should read the labels very carefully. Although avoiding wheat altogether is the best option, medications may also be necessary to manage allergic reactions to wheat. It is important for pharmacists to help identify patients who may be struggling with unknown or undertreated food allergies. Pharmacists can ensure that patients receive the proper medications and are following an appropriate diet.

Case: Gastrointestinal Problems

MD is a 37-year-old female who recently started using your pharmacy to refill her prescriptions. MD walks up to the pharmacy counter to drop off a new prescription for her husband. Before she leaves, she asks if she can have a moment of your time to discuss a private matter. You take her to your counseling area and ask how you can help. MD sighs and explains that she is frustrated with her health. She is suffering from bloating, gas, diarrhea, and other gastrointestinal (GI) problems. Her quality of life is suffering.

She expresses that she is embarrassed and uncomfortable when dining outside of her home, and that she is only comfortable in loose-fitting clothing. She was recently diagnosed with irritable bowel syndrome and hypothyroidism. She has not started any medications and is waiting for a second opinion. When you ask if she has had blood work to diagnose celiac disease, MD states that she has not. She has, however, started eating a gluten-free diet and has been feeling somewhat better. She wonders if she may have gluten sensitivity, and asks you if she should “go gluten free.”

You are happy to refer her to a local dietician. However, you are somewhat concerned about the accuracy of her self-diagnosis and its impact on her current medications. If it is suggested that MD follow a gluten-free diet, you want to ensure that her medications also are gluten free. You supply MD with a telephone number for a local dietician. You also ask MD if she would be interested in stopping by the pharmacy with all of her medications. You explain the concept behind brown bag sessions. MD agrees to participate in a brown bag. She is looking forward to your advice and to alleviating her GI problems.

In preparation for MD’s brown bag session, you pull her medication profile to determine whether any medications contain gluten. You also double-check for any adherence issues and interactions. MD’s medications consist of:

• Montelukast 10-mg tablet once daily
• ProAir HFA 1 to 2 puffs by mouth every 4 to 6 hours as needed (flagged for overuse/early refills for the past 4 months)
• Sertraline 50-mg tablet once daily
• Lo Loestrin Fe tablets once daily
• Ibuprofen 400-mg tablets; 1 to 2 tablets, as needed, twice daily for headaches

Three weeks later, MD stops by your pharmacy and is smiling as she approaches your counter. She thanks you again for your referral and tells you she is feeling happier and healthier. She hands over a bag of medications for you to review. As you look them over, you notice the following additional OTC medications:

• OTC calcium carbonate 500-mg chews, as needed
• OTC Pepto-Bismol, as needed
• OTC aspirin 81 mg, chewable, daily
• OTC women’s multivitamin, daily
• OTC vitamin D 400 IU, daily
• OTC probiotic, daily
• OTC evening primrose, daily

MD explains that her new physician and dietician have given her a diagnosis of sensitivity to gluten. She has been avoiding gluten, when possible, and is developing better cooking and shopping habits. Her undesirable symptoms are subsiding, and she is taking fewer medications as a result. Yet, MD tells you that committing to being gluten free is no easy task. As MD starts to feel better, how can you help ensure that she stays on the right track? What do you notice about MD’s OTC medications?

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.