Pharmacy Connection, Nov/Dec 2001
Sitting down with a patient in a private counselling room is probably the most ideal situation for identifying and resolving drug-related issues. Quiet times during the week, such as a Wednesday afternoon or a weekday evening, may be the most convenient times for pharmacists and patients to meet to discuss medication concerns. Pharmacists can encourage patients to make an appointment to meet for an hour. Planning ahead gives the pharmacist time to prepare for the meeting by reviewing the patient profile and identifying any potential issues.
It is helpful to have something for the patient to complete in the counselling room when they first arrive. Many people arrive early and this gives them something to do while the pharmacist is finishing up other matters in the dispensary. The ‘Just Checking’ questionnaire produced by CPhA is an excellent tool to use in this type of interview. It also helps the pharmacist focus on the drug related issues from the patient’s point of view. It’s important to review this with the patient to clarify specific details and establish priorities for their own health concerns. This is a good opportunity to address lifestyle issues such as smoking, alcohol and caffeine consumption in a non-judgmental way. Clarify any allergies as well as other medical conditions and document any significant details in the patient profile after the interview (unless you’re lucky enough to have a computer terminal in the counselling room).
Diabetic patients usually present with a variety of challenging issues because their drug regimens are often complicated by the fact that they usually have other medical conditions needing additional medications. This scenario is based on a 78-year-old female, Di Abbott, who has hypertension, osteoarthritis, GERD, depression, and type II diabetes.
Since the pharmacist, Matt Forest, had asked Di to bring all her medications with her to the interview, he separated the prescription drugs from the OTCs and herbals, and started by reviewing the dosages of each.
Matt: “Do you know why you are taking these glyburide tablets?”
Di: “Those are my sugar pills.”
Matt: “Can you tell me how often you are taking them.”
Di: “I’m taking 2 in the morning now and only 1 at night.”
Matt: “What about these metformin tablets?”
Di: “ Those are sugar pills too, but I don’t take them 3 times a day anymore because they give me diarrhea. I take at least one everyday and sometimes 2.”
Matt: “Does Dr. Lance know how you are taking these now?”
Di: “ I think so. I told him I didn’t like taking those big ones.”
Matt: “What kind of blood sugar levels are you getting when you test everyday?”
Di: “I test at least twice a day, before breakfast and before supper. My numbers are always between 8 & 10. I know that you told me that my levels should be between 4 and 7, but that is impossible for me right now. I’m walking everyday and I try to stick to the diet that the dietician gave me a few months ago. What else can I do to get my sugar down? I don’t want to go on insulin like my mother did.”
Matt: “It seems to me that the metformin is not helping you; in fact it is causing side effects which prevent you from taking an appropriate dose. Would you like me to contact your doctor and explain your situation?”
Di: “That would be great. I’m not going to see him again for a couple of months.”
Matt reviewed all other medications with Di. He was surprised to find several outdated medications (Tylenol® #3 and vitamins from 1997) as well as herbal preparations (Evening primrose oil and St. John’s Wort from 1998). Matt expressed his concern about keeping these old products around the house and the dangers of taking herbals with her prescribed medications. Di agreed to let Matt discard all of the old bottles. He discovers that she has a good understanding of most of her medications and her major concern is her high blood sugar levels. She also thinks that she is taking too many medications and that some of them may be working against each other.
Matt explained to Di that he would be sending a note to Dr. Lance in the next week or two and agreed to call her at home when he gets a response.
Dear Dr. Lance:
I have met with your patient Di Abbott recently and have reviewed all medications with her. Please find enclosed a summary of my interview with her.
Current Prescribed Medications:
Glyburide 5mg 2 AM & 1 HS
Metformin 500mg 1 TID AC
Desipramine 25mg 2 Daily
Ranitidine 150mg 1 BID
Dyazide® 1 Daily
Arthrotec® 50mg 1 BID
PRN Medications:
Imodium®, HC Cream 1%. Tylenol® #3, Tylenol® E.S., & Robaxisal®
Other Medications:
Beano®, Gas-X®, vitamin E 400U, Gravol®, Gaviscon®, Evening Primrose Oil, St. John’s Wort
Overview:
Di seems to be compliant and aware of the appropriate dosages and indications for most of her medications. We discussed the problems related to taking herbal medications along with prescribed medications (eg. St. John’s Wort and Evening primrose oil with desipramine for depression). She agreed to let me discard those products along with outdated vitamins and Tylenol® #3 tablets.
Her major concern is high blood sugar levels despite compliance with diet and exercise programs. She is not tolerating metformin at this time. She was originally taking 500mg TID, but has cut back to BID and sometimes only once daily due to diarrhea and cramping.
Recommendations:
1. Continue metformin on once daily dosage and increase dosage of glyburide 5mg. to 2 tabs (10mg.) BID.
2. Or discontinue metformin and try Avandia®, Actos®, or GlucoNorm® along with a lower dose of glyburide.
I look forward to your comments about these recommendations and I will continue to follow-up with Di on the telephone and whenever she comes into the pharmacy during the next few months.
Within a few days, Matt received a note from Dr. Lance. He wrote:
“I was interested in your recommendations for Di Abbott but feel that her prescriptions are the least of her problems because she avoids contact with her doctors at this time. I believe that she is depressed and none of these recommendations deal with the actual problems occurring in her life. None of these recommendations will make a difference to morbidity or mortality. You seem to look at the drugs and not at the whole person. Things are rarely black and white. There are many issues here and diabetes is of secondary importance today.”
Matt was surprised and upset to receive this kind of response from Dr. Lance because they had always had a good professional relationship in the past. He carefully reconsidered all the issues and decided to call Di and tell her that Dr. Lance did not want her to change anything at this time. Matt suggested that Di continue to document her sugar levels at least twice daily, then discuss her situation with Dr. Lance at their next visit. Matt continued to keep in touch with Di every couple of weeks whenever she came into the pharmacy. He documented her blood sugar levels and symptoms into the note section of the computer.
It was interesting to see that Dr. Lance gave Di some samples of Avandia® at her next visit. He told her to discontinue metformin and reduce the dosage of glyburide. Although Dr. Lance never formally acknowledged the value of the recommendations Matt gave to him, Matt was please that Dr. Lance implemented one of his suggestions. He knew that he had to try to advocate on behalf of his patient.
It also became obvious to Matt that there are sometimes situations/relationships between doctor and patient that are not always evident to the pharmacist. Matt had to agree that pharmacists often focus on the patients drug profile, rather than the whole patient, because they often don’t have all of the information they need. Although the pharmacist does not always have the patient’s diagnosis, it can often be determined by questioning the patient directly. The priorities which a physician has set for a specific patient are extremely difficult to determine.
