The Heart of the Matter

Patients who suffer from chronic conditions may be at a higher risk for medical-related episodes and errors. These patients take a number of different medications, visit a variety of health care providers, and may use more than one pharmacy.

Often, patients experience short- or long-term changes in their health that require adjustment of maintenance therapy. They may communicate with community pharmacists on a regular basis for necessary follow-up care. Refill medication counseling is an excellent opportunity for pharmacists to identify vulnerable patients. By asking open-ended questions about possible concerns or changes, a pharmacist can determine if further review is necessary. Brown bagging provides a smooth introduction for a pharmacist to participate in and offer extended counseling concepts, such as medication therapy management (MTM). It is also an essential safety and educational tool pharmacists can use to measure and ensure quality care within the health care system.

Hypertension is an independent risk factor for coronary artery disease, stroke, and renal failure. It is a silent condition affecting many patients. Several guidelines should be reviewed and understood when treating patients with hypertension. It is important to discuss blood pressure goals, dietary habits, and medication regimens during counseling, brown-bag checkups, and MTM sessions.

The Case

HR is a 75-year-old overweight woman who is a regular customer at your pharmacy. HR has become more aware of her weight and prescribed medications in light of a recent health scare involving a family member and numerous news stories and political messages on television regarding health care. You notice her growing concern by her increased number of questions during your counseling sessions, particularly related to her heart, diet, and financial issues.

Today, HR stops in the pharmacy to pick up her late refill prescription for levothyroxine. You counsel her on the potential for misuse and explain the concept behind a brown-bag session. You tell her that due to her chronic disease states, you believe she would be an excellent candidate to participate in a review. You ask HR if she would be interested in bringing all of her medications to the pharmacy and reviewing them with you for proper use.

HR is excited to have your attention and participate in this free service. She explains that she is starting to get confused when trying to keep her medications straight. She is tired and lacking energy. HR stresses that she cannot afford a hospitalization like her family member recently experienced. She schedules an appointment to meet with you tomorrow during the hours when you have overlap pharmacist coverage.

To prepare for tomorrow’s session, you pull up HR’s pharmacy profile:

• Losartan 50 mg once daily

• Furosemide 40 mg once daily every morning

• Atorvastatin 40 mg once daily every evening

• Levothyroxine 15 mcg once daily every morning

• Duloxetine 60 mg once daily

• Metoprolol 100 mg daily

HR arrives the next day for your appointment and empties her brown bag onto the counter. You notice these additional medications:

• OTC aspirin 325 mg once daily

• Calcium carbonate 1000 mg once daily

• Adult multivitamin once daily

• OTC omeprazole 20 mg once daily

• OTC fish oil 4 capsules daily

• Expired clopidogrel 75 mg once daily (last filled at a competitor pharmacy 1 year ago)

• Expired rosuvastatin 20 mg daily (last filled at a competitor pharmacy 1 year ago)

As you review the medications for accuracy, HR confides that, due to her recent memory and vision issues, she is not always able to maintain adherence, sometimes forgetting to take certain medications or not following her prescriber’s directions for use. She also admits to no longer having a primary care provider because long-distance driving has become a challenge for her and her transportation resources are unreliable. HR cannot remember the last time she had laboratory work performed. She has been monitoring her blood pressure more frequently at the pharmacy and has questions about goals and diet.

You instruct HR on how to take a reliable blood pressure reading, and she expresses interest in purchasing an inexpensive cuff for home use. You take a thorough medical history and discover HR has 2 cardiac stents and is not actively seeing a cardiologist. Thus, she is very interested in participating in the MTM session you offered as a follow-up after you connect her with the appropriate specialists.

How would you properly review HR’s medication profile and what advice could you offer her during the brown- bag checkup? HR needs to establish care with local providers to help her effectively manage her conditions. How can you help refer her to the correct indi- viduals who will have a vested interest in her health?

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 www.PharmacyTimes.com/blogs/compounding-in-the-kitchen. Read, and enjoy!