Medication therapy management and OTCs

Abstract

Recently I completed a semiannual comprehensive medication review for a 65-year-old patient who has several medical problems complicated by pain, including osteoarthritis, neuropathy, muscle spasms, and cervical dystonia. In reviewing his prescription medications, I noted that he was taking diclofenac 150 mg daily, tramadol 150 mg daily, and pregabalin 25 mg daily. I asked his caregiver about the patient's OTC medications, and he indicated that the patient was taking acetaminophen 1,950 mg daily and ibuprofen 200 mg as needed (1–2 tablets/d). My immediate concerns were the patient's increased risk of a gastrointestinal bleed caused by his use of two NSAIDs and that his pain be adequately controlled. Fortunately, the patient was taking the gastroprotective agent esomeprazole 40 mg twice daily, but that did not mean he was without risk. My workup included patient-caregiver education, alerting the physician to the patient's OTC medication use, requesting lab work, and suggesting adjustments in his pain medications. This case demonstrated the importance of asking patients about their OTC medication use. Patients may believe that OTC medications are safer than prescription medications and may not realize that taking an OTC drug can increase their risk of an adverse drug event like the case above. Community pharmacists can play an important role in triaging patients who may be seeking OTC medications for a particular ailment. Using a systematic approach to working up patients—the same approach used for medication therapy management—pharmacists can determine whether to advise patients to self-treat, refer patients to their primary care provider, or suggest non-pharmacotherapy approaches. An article I read recently highlighted the role of community pharmacists in advising older patients on OTC products.1.Gerontologist. dol:10.1093/geront/gnt130.Google Scholar “Inform patients of the risk of potential drug therapy problems associated with OTC therapy, including adverse effects and drug interactions, dosing issues, duplication of therapy, or inappropriate therapy.” Twenty-one community pharmacists from community, independent, or clinic pharmacies were asked to participate in a focus group in which they were given a vignette about an older woman seeking advice on an OTC sleep aid. The participating pharmacists described a mental model they used in collecting information from the patient and/or caregiver to assess the situation appropriately and recommend an OTC product. The pharmacists wanted to attain the follow four goals during their discussion with the patient and/or caregiver:■Goal 1: Assess medication profile.■Goal 2: Establish if patient has seen a physician for the condition.■Goal 3: Identify characteristics and causes of the symptoms.■Goal 4: Understand the relationship between the medication profile and causes of condition. The pharmacists' recommendations varied from nonpharmacotherapy strategies, including appropriate sleep hygiene, to homeopathic sleep aids to physician referrals. Of note, the pharmacists did not recommend a medication considered potentially inappropriate for older adults. Community pharmacists can help patients decide if they can appropriately self-treat a particular ailment with an OTC product. But it is important that pharmacists use a systematic approach to collecting a thorough patient history so they have the needed clinical information for an adequate assessment (e.g., chief complaint, description of the patient's signs and symptoms, current medications, past medical history, and past treatments). This information can be gathered quickly and efficiently if pharmacists are systematic and open-ended with their questions. Pharmacists can then provide effective professional advice. In addition, pharmacists need to be aware that their patients may be taking OTC products without their knowledge. Pharmacists should ask patients about their OTC use when performing comprehensive medication reviews and inform patients of the risk of potential drug therapy problems associated with OTC therapy, including adverse effects and drug interactions, dosing issues, duplication of therapy, or inappropriate therapy. Pharmacists should communicate to prescribers when drug therapy problems occur with OTC medications so that patients are appropriately monitored.