Gastrointestinal Issues: How Brown Bagging Can Bring Clarity

JULY 21, 2018
Jill Drury, PharmD
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 helping to identify potential problems and concerns that may require follow-up with prescribers or a medication therapy management session. It is essential that a pharmacist’s workflow allow for brown bag consults, which can do the following:
  • Develop the patient–pharmacist 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
Gastrointestinal (GI) conditions are major causes of health care use in the United States. Many visits are made to community outpatient care centers, health care providers, and hospitals for digestive system symptoms such as constipation, diarrhea, heartburn, and reflux. GI disorders can be challenging to properly diagnose and treat. The diagnostic evaluations performed on patients can involve a variety of invasive procedures that some individuals are not always willing to undertake or cannot afford. For many, the topic of GI discomfort can be uncomfortable, and that may prevent them from seeking professional care. Many patients opt to bypass the health care system and self-diagnose and self-treat with the many OTC medications available. Some patients do not seek help until the symptoms become unbearable, and by that time, complications may have occurred. Understanding the basic characteristics of some GI issues, the challenges behind patient care, and reviewing available treatment options are essential to providing the best comprehensive patient care in the pharmacy.

LS is a 51-year-old woman who is a returning customer. She works for a small pharmaceutical company and travels often for work. LS is a self-proclaimed foodie and enjoys unique restaurants in the various cities to which she travels and experiments with new flavors. She stops in to pick up her early refill prescription for her albuterol inhaler and epinephrine injection. LS is not her usual energetic self, and when you ask how she is doing, she does not give you her typical smile. She seems shy about the issue, so you do not press. You counsel LS on the medications and quickly explain the concept behind brown bag and medication therapy management (MTM) sessions. You tell her that because she suffers from asthma, food allergies, and past compliance issues and is on multiple medications, she would be an ideal candidate to participate in a brief review. You ask whether LS would be interested in bringing in all her medications and going over them with you for proper use. She says that she is not feeling well and would be happy to have your attention and participate. But LS stresses that she has limited time. She sets up a brief appointment to meet later in the day when things slow down a bit in the pharmacy.

To prepare for the session, you pull up her pharmacy profile so you can compare it with what is in her brown bag:
  • Albuterol inhaler, 1 to 2 puffs every 4 to 6 hours, as needed
  • Epipen (epinephrine injection), inject as directed during a reaction (she has peanut and shellfish allergies)
  • Fluticasone propionate, 250 μg/salmeterol 50 μg diskus, twice daily 
  • Ibuprofen, 600 mg every 6 to 8 hours, as needed use for cramps and stomach pain
LM arrives later in the day for your appointment. She empties her brown bag, and you notice these additional medications:
  • Adult multivitamin with iron, once daily
  • Calcium carbonate, 500 mg, as needed daily
  • OTC brand Advil (ibuprofen), 200 mg, as needed
  • OTC esomeprazole, 20 mg, twice daily
  • OTC famotidine, 20 mg, twice daily
  • OTC omeprazole, 20 mg, once daily
As you review the medications for accuracy, LS tells you about her growing number of food allergies and stomach discomfort. She also says that she is not always able or willing to seek medical advice. LS says she experiences lots of indigestion that can cause her to vomit, feels full quickly after meals, and often gets intense stabbing pain after dinner. She says that her medications seem to provide only temporary relief and her quality of life is not what it was a few months ago. Yet LS says that she prefers to browse the pharmacy aisles in private, use internet search engines to find symptom descriptions, and make treatment decisions on her own. You ask about her goals, and she tells you she just wants quick comfort and relief so that she can drink and eat whatever she wants like a “normal” person. You briefly discuss her diet and your concerns. LS is on many OTC medications and has not disclosed these to her primary provider. Moreover, she seems to be spending a significant amount of money on duplicate medications. It is also important to note that LS has never received a medical diagnosis of any GI issue, but it is clear she needs to be referred to identify any underlying conditions and determine symptom treatment. You also question the appropriate use of her epinephrine injection. It has been refilled more often than usual in the past 6 months. Because of the brown bag session, LS is very interested in participating in the MTM session to help further investigate her concerns and issues.

Editor’s note: This case is not based on an actual patient.
Jill Drury, PharmD, is a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy degree from Midwestern University College of Pharmacy.