Pharmacy Connection January/February 2001

In the pharmaceutical care model, pharmacists are actively trying to identify , prevent and resolve drug-related issues. The issues are not always complicated; often simple situations occur in every day practice. Communication is an important tool to allow us to proceed through this model. Pharmacists need to be able to convey their concerns to the patient and the physician in an effective manner. In the following scenario, dialogue enables a resolution to the issues.

Scenario
Tina Bones is a petite, 62-year -old woman who comes into the pharmacy every few months.

While refilling her prescription for prednisone 5 mg, the pharmacist notices that the last fill date for her Didrocal ® kit was five months ago. The pharmacist thinks about how he is going to approach the subject of non-compliance.

Pharmacist: Tina, has there been a change in the medication you are taking for osteoporosis? I notice that the last time you filled your Didrocal ® kit was five months ago.

Tina: I stopped taking those ages ago. I told my doctor I couldn’t swallow big pills but he gave them to me anyway.

Pharmacist: I think it is really important that you take something to prevent your osteoporosis from progressing. Particularly now that you are on prednisone, you need to take some action to prevent bone loss.

Tina: Well there is no way that I can swallow those pills. So what else do you suggest?

Pharmacist: Would you like me to contact your doctor to see if there is another medication that you could take instead? I can show you some that are smaller , easier to swallow and also very effective.

After looking at the size of the tablets, Tina agrees to try them if her doctor orders her a prescription.

The pharmacist calls the doctor ’s office and speaks to the receptionist about Tina Bones's situation. He asks if the doctor can call him back later to discuss the alternatives.

Dialogue with Physician

Physician: I understand that Mrs. Bones has not been taking her Didrocal ® as I had thought. Do you have any suggestions?

Pharmacist: I wonder if Fosamax ® might be appropriate for this patient. The tablet is smaller and she does have a drug plan, so cost is not an issue.

Physician: Sounds good to me. Give her Fosamax ® 10 mg daily for three months then ask her to make an appointment to see me.

The pharmacist calls Mrs. Bones and asks if she would be able to come in tomorrow afternoon when it is quiet to discuss her new medication.

The Next Day
When Tina comes in, the pharmacist explains how important it is to take Fosamax ® at least one half hour before the first food or medication of the day with a large glass of plain water. She should also refrain from lying down for at least 30 minutes after taking the tablet.

Pharmacist: Are you taking any calcium supplements?

Tina: No, I don't need to.

Pharmacist: What about vitamins with calcium in them?

Tina: No.

Pharmacist: Tell me how much calcium you get in your diet. Do you drink milk, eat any cheese, yogurt or other dairy products?

Tina: Well, I always have milk in my coffee and I drink a big glass of warm milk every night at bedtime. That’ s a lot more than my friends, you know. I'm not worried about putting on weight like they are. I could stand to gain a few pounds, don’t you think?

Pharmacist: Yes, you do have a petite bone structure, which is considered to be a risk factor in osteoporosis. Unfortunately , there’s little benefit from milk in coffee. The caffeine prevents absorption of calcium and excessive caffeine intake is also another risk factor for osteoporosis. I would suggest that you continue to have your glass of milk at bedtime as well as adding other calcium supplements.

Tina: Oh. So how do I begin?.

Pharmacist: There are several ways to incorporate calcium into your diet. Here is a chart of food products with their calcium content. You should try to get between 1,000 and 1,500 mg of elemental calcium each day. If you are unable to get enough calcium from your diet, you can consider a chewable or liquid product that we have in the pharmacy. When choosing a product, you also want to look for something with vitamin D, which helps improve the absorption of calcium. The recommended dosage is 400 to 800 IU of vitamin D. One point to remember is that calcium in any
form should be taken later in the day , at least two hours after the Fosamax ® dose.

Tina: This is a lot to remember.

Pharmacist: Here is a weekly calcium calculator to help you get started. Take it home and fill it out.
Bear in mind that Fosamax ® cannot do all the work alone. You need to consider your daily calcium intake, as well as exercises to strengthen your bones and improve balance to help prevent falls.
I will give you a call later next week to see how it is going.

Tina: Thanks for all your suggestions. It has been very helpful to learn so much about simple things I can do everyday to help keep my osteoporosis from getting worse. I look forward to your call next week. I’ll probably have some more questions for you by then.

Calcium Content of Some Common Foods Buttermilk 250 ml (1 cup) 300mg elemental calcium Cheese (firm) 50gm 350mg elemental calcium Milk (homo, 2%, 1% or skim) 250ml (1 cup) 315mg elemental calcium Processed Cheese 2 thick slices 384mg elemental calcium Swiss Cheese 50gm 450mg elemental calcium Yogurt (plain) 175gm (3/4 cup) 290mg elemental calcium Almonds 125ml (1/2 cup) 200mg elemental calcium Salmon (pink-canned with bones) 1/2 a 213 gm can 225mg elemental calcium Sardines (canned with bones) 11 small sardines 210mg elemental calcium Broccoli 125gm (1/2 cup) 38mg elemental calcium

Author
Midge Monaghan: B.Sc.Phm. Pharmacist, Dell Pharmacy.

Kerry Monaghan: B.Sc., B.Sc (hons) Pharm. Pharmacist, Dell Pharmacy.