Brown Bag Consult: Watch for Cardiac Red Flags

Brown bag consults can be essential educational and safety tools to measure and ensure quality care. By asking patients to bring in all their current medications, including OTC, mail-order, specialty, and herbal products, pharmacists can guarantee appropriate and up-to-date care.

Pharmacists are key providers in the continuum of care, consistently identifying potential problems and concerns that may require follow-up with prescribers or a medication therapy management (MTM) session. It is essential that a pharmacist’s workflow allow for brown bag consults, which can do the following:

• Develop the pharmacist-patient relationship to help create better individualized service, forge patient loyalty and trust, and prevent medical errors
• Provide insight into a patient’s lifestyle and quality of care
• Show how well patients understand their conditions and medications

Offering to review medications one-on-one gives pharmacists the opportunity to connect with patients by serving as trusted medical professionals in the community. Brown bag sessions do not have to be time-consuming scheduled events. They can be offered anytime a pharmacist thinks that a patient needs follow-up care after a typical counseling session.

Patients should weave preventive health care into every aspect of their lives, as it paves the way for better outcomes and quality of life. By being active, eating more nutritious foods, maintaining a healthy lifestyle, and staying on top of wellness screenings, individuals can be their best selves. The community pharmacy is a hub for preventive care and services. Pharmacists play a big role in keeping patients safe and helping them identify conditions early, potentially preventing hospitalizations and unnecessary doctor visits. They can also offer vaccines, screenings, and services such as MTM that can reduce costs.

Through these services, pharmacists have chances to connect with patients. By understanding what OTC and prescription medications a patient may be taking, in addition to any herbal supplements and vitamins, pharmacists can better assess quality of care and safety.

MD is an 82-year-old woman who has been a patient for a few years. Her daughter often helps call in or pick up her medications, as MD does not like to visit the pharmacy these days. MD has become more aware of her memory issues and depends on her daughter for support. You talk to MD on the phone and sense her growing concern based on the number of questions during your counseling sessions specifically related to her anxiety and heart issues. Today her daughter stops in to pick up MD’s late refill prescriptions for atorvastatin and levothyroxine. You counsel her on the potential for misuse and explain the concept behind a brown bag session. You tell her that because of MD’s chronic disease states, you think MD would be an ideal candidate to participate in a review. You ask her daughter whether she would be interested in bringing in all MD’s medications and reviewing their proper use with you. MD’s daughter thinks that this is an excellent idea because she does not understand her mother’s health and medications very well. She explains that she feels confused when trying to keep MD’s medications straight and is embarrassed to ask questions about medications that she cannot pronounce. She schedules an appointment to meet with you tomorrow when you have overlap coverage.

To prepare for tomorrow’s session, you pull up MD’s pharmacy profile to compare it with what is in her brown bag:

• Atorvastatin, 40 mg, once daily, every evening
• Duloxetine, 60 mg, once daily
• Enalapril, 40 mg, once daily
• Furosemide, 20 mg, once daily, every morning
• Levothyroxine, 25 μg, once daily, every morning

MD’s daughter arrives the next day for the appointment and is ready to take notes. She empties MD’s brown bag, and you notice these additional medications:

• Adult multivitamin, once daily
• Calcium carbonate, 1000 mg, once daily
• Expired clopidogrel, 75 mg, once daily, last filled at a competitor pharmacy 2 years ago
• OTC acetaminophen, 500 mg, every 4 to 6 hours, as needed
• OTC aspirin, 81 mg, enteric coated, once daily
• OTC fish oil, 4 capsules, daily
• OTC ibuprofen, 200 mg, every 6 to 8 hours, as needed
• OTC omeprazole, 20 mg, once daily

As you review the medications for accuracy, MD’s daughter says that her mother has not been feeling well the past 2 weeks and has a lot of left-arm pain. She has been taking extra OTC pain medications that have not been helping. MD has not had much of an appetite, and the medications seem to be giving her an upset stomach. This concerns you because of MD’s cardiac history, and you tell her daughter to take her mother to the emergency department (ED) as soon as possible so MD can be evaluated and monitored. MD’s daughter also tells you that her mother has been dizzy and is having problems with her short-term memory. MD’s daughter cannot remember the last time she took MD for laboratory work or helped her monitor her blood pressure. You also find out that MD has 3 cardiac stents and is not actively seeing a cardiologist. MD’s daughter says that she can take her mother to urgent care. You again stress that MD needs immediate medical attention at an ED, and her daughter agrees to take her mother to the hospital.

MD’s daughter calls you the next day to tell you that her mother’s cardiac enzymes were elevated and that she had a heart attack. MD also needed 2 additional stents placed. This is an opportunity to educate about diet and heart health.

How else can you help MD’s daughter with her mother’s current medications and anticipated new ones? Is there a way to find MD additional support to help relieve her overwhelmed daughter? MD’s daughter tells you that her mother will have to attend cardiac rehabilitation.

Editor's note: Case is not based on an actual patient.

Jill Drury, PharmD, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin.