Pharmacy Connection March/April 2001

For more than 10 years we have been learning about pharmaceutical care. Countless articles and presentations have advocated incorporating this philosophy into pharmacy practice. However, just looking at the flow charts and list of steps involved can be overwhelming and can cause pharmacists to wonder how they could possibly implement this concept in a busy community pharmacy.

The first critical step is to change your thought process to focus on the patient rather than a drug or product. Keep in mind that not every patient has a drug-related problem, and the process starts with just one patient and one drug-related problem. If the patient is a regular client of the pharmacy you probably have already established a good working relationship. By asking just one or two simple questions, you may be able to identify a real or potential problem. It is then a matter of determining what the desired therapeutic outcome is, discussing this with the patient, communicating with the physician and/or other health care professionals as needed, and implementing and following up on your recommendation.

Eight categories of drug-related problems have been identified:

• Untreated condition
• Wrong drug for condition
• Subtherapeutic dose
• Overdosage
• Adverse drug reaction
• Drug interaction
• Failure to receive a drug

Drug use without indication
In this, the first in an upcoming series of articles for Pharmacy Connection, we will look at the category untreated condition. In this series you will see how a community pharmacist has been instrumental in identifying and helping to resolve a drug-related problem from each of these categories.

Case
Mr. Sam Miller approaches the dispensary counter to pick up his refill for blood pressure medication that he ordered earlier by telephone. You notice he has a container of Slim Fast® in his hand. He asks:

Mr. Miller: How many calories are in this product? I have decided I need to lose some weight.

You know that Mr. Miller is overweight, so you ask him some pertinent questions.

Pharmacist: Do you mind if I record your height and weight in the computer to give us a baseline?

Mr. Miller: Don't tell anyone, but I weigh 269 pounds and I am 5' 10". I probably put on about 20 pounds in the last three months since I changed jobs.

Pharmacist: Have you changed your diet or been exercising less regularly?

Mr. Miller: Yes, since I started my new job it has been such a hectic time I haven't been able to go for my regular walks or prepare healthy meals. I often find myself going through the drive-through on my way home, but I know that has to change.

Pharmacist: Yes, it does. According to my calculation your body mass index (BMI) is 38.5. In addition to contributing to high blood pressure, your extra weight can also increase your risk of heart attack, diabetes, cancer, gall bladder disease and osteoarthritis. Even a 10 kg weight loss can decrease your blood pressure, reduce your risk of developing diabetes by 50% and reduce your risk of dying prematurely. You will probably also feel a lot better.
Have you talked with your doctor about losing weight? When was the last time you saw him?

Mr. Miller: I haven't seen him for quite a while because I don't like to bother him.

Pharmacist: If it is okay with you, I would like to talk with your doctor. I will need to let him know what your current weight is. Slim Fast® is a reasonable product for people who need to lose a few pounds, but I would like to talk with Dr. Hayes about your using a new prescription medication called Xenical® . It is indicated for generally healthy people with a BMI of >30. Patients such as yourself with high blood pressure may benefit even more. It works by blocking absorption of about 30 per cent of the fat in food, and the fat that is not absorbed is excreted in your stools. It works best when combined with an increase in physical activity and a mildly low-fat calorie-reduced diet.
Here is some general information about the drug. The company that makes it also provides a Body Wellness Program with meal planning and exercise information, and they have a toll-free support program that you can call. I will be able to give you that additional information when you get the first prescription filled.

Mr. Miller: That sounds like a good idea. Should I go and see Dr. Hayes?

Pharmacist: Why don't you let me contact him first to discuss the possibility, then I can let you know if he wants to see you? I should mention that Xenical® is relatively expensive (about $150 for a four-week supply). You may want to check with your drug plan to see if they will consider paying for it. I will give you a note with the name of the drug, the drug identification number and your BMI.

Mr. Miller: Okay. I will call them tomorrow.

Pharmacist: In the meantime, I will talk with Dr. Hayes. May I call you tomorrow evening after work, to let you know what he says?

Mr. Miller: Please do.

Sam Miller pays for his blood pressure medication and leaves the store, and the pharmacist composes a note and faxes it to the physician.

Early the next morning Dr. Hayes calls the pharmacy.

Dr. Hayes: Hi, Bill, this is Dr. Jim Hayes. I got your note about Sam Miller. I haven't seen him for more than four months. I appreciate you letting me know about his recent weight gain. I have put your note in his file. I agree than Xenical® is a reasonable choice. Give him one box, one capsule three times/day with two repeats.

Pharmacist: Do you think a weight loss of 10 pounds in three months is feasible?

Dr. Hayes: Sure. Can you let me know how he is doing?

Pharmacist: I would be happy to. I will follow up with him at least monthly, check his weight and blood pressure at each refill, and let you know the results when we call for additional refills at the end of three months.

That evening the pharmacist calls Mr. Miller to inform him the doctor has authorized a prescription for Xenical® .

Mr. Miller: That's great. My drug plan said they would reimburse me, but they need something in writing from you or my doctor.

Pharmacist: I can give you a copy of the Xenical® prescription and record on it your initial weight and blood pressure, which you can send to them. Then I will prepare a chart to keep on your computer file. Each time you come in to pick up your prescription refill, you can let me know what your weight was that morning. We will measure your blood pressure here, then record these numbers in the chart. Every three months you can send a copy to your drug plan and I will send a copy to the doctor.

Patient: You are great. I knew your pharmacy provided good service, but this is more than I expected!

Authors
Prepared by Mary Nelson, B.Sc.Phm., the new Pharmacist Manager at Dell Pharmacy in Burlington.
Reviewed by Midge Monaghan, B.Sc.Phm., the Pharmacist Manager at Dell Medical Pharmacy in Hamilton.