Patient Education

Medication Therapy Managment: Reducing Healthcare Cost And Improving Quality Of Life

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There are memories that deserve resurfacing, especially those which compel a Community Pharmacist to seek purpose in alleviating patient concern and unease. At the heart of ePharmacistNow is a story experienced by every patient who has ever had to interact extensively with a healthcare professional. While working in a national drug store chain, I was drawn to an elderly patient carrying a small paper bag filled with prescription medications. The woman sought my help, desperate to make sense of what she considered an unusual circumstance. Yet, managing ones own collection of medications and the frustrations that often accompany them are not as isolated as many people think. More than 3.5 billion prescriptions are written annually in the United States (Sommers 2005) and four out of five patients who visit a physician leave with at least one prescription.

One after another, each prescription placed in front of me revealed the patient’s growing concern. She had medications prescribed by several physicians which were filled by different pharmacies, some looked different but overlapped in purpose. Medications at different dosage strengths with varying instructions, including medicines that should not be taken together because of drug interactions as well as expired ones were there to overwhelm her. In addition to her medication concerns, her guilt for monopolizing my attention away from other pharmacy-related functions provoked a feeling of remorse. As a Pharmacist, it was disturbing to witness a patient so desperate that she felt the need to apologize for a service that should be necessary in her circumstance.

The true nature of a community pharmacy often leaves its Pharmacists constrained with time and even an extensive consultation would leave them vulnerable to a backlogging of responsibilities. It is not uncommon for a patient to decline a consultation for this reason, believing that they can save time by managing their own prescriptions. However, the complexity of handling these issues increases for an individual who has various disease states with multiple medications from their physicians. As a result, physicians may become overwhelmed, believing that their prescribed medications might not be optimally used for their patient’s well being. Each year, 290 billion dollars are spent on avoidable medical cost due to medication non- adherence: hospitalization (33-69%), preventable adverse drug events (21%), and deaths (125,000 per year) (Gurwitz 2003, McCarthy 1998).

These statistics gave way to Medication Therapy Management (MTM), a pharmaceutical care service using targeted medication counseling in congruence with a comprehensive medication review system. Pharmacists engaging in Medication Therapy Management can exclusively focus on this type of effort, involving detailed care elements that a typical Community Pharmacist would not be able to adequately provide given their time constraints. The desired outcome helps patients optimize their drug therapy by allowing them to understand how their medications work best.

A study in American Society of Health-System Pharmacist (2009) shows that Pharmacists who are working with primary care providers, saved an estimated $1,123 per patient in medication claims and $472 in medical, hospital, and emergency visit costs per year. Other studies show that the delivery of this service demonstrated a return of investment (ROI) as high as $12 for every dollar spent on Medication Therapy Management (Isetts, Schondelmeyer 2008) and an average of $5 for every dollar spent. This is a conservative estimate. The ROI is likely to be much higher because practitioners routinely underestimate the impact on a patient’s life and it is difficult to put a number on high patient satisfaction.

Had I had the opportunity to sit down and talk to her without concern for time, I know I could have impacted the patient’s life in a meaningful way. Medication Therapy Management (MTM) will take Pharmacist-patient interaction to a whole new level in order to achieve positive, measurable health outcomes in a cost effective manner, allowing them to live happier, healthier and ultimately fuller lives.

Lactobacilus acidophilus (L. acidophilus) Probiotic

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Lactobacilus acidophilus is familiarly known as L. acidophilus or just Acidophilus. It is the most commonly used probiotic and is known as a “friendly” bacteria. It exists naturally in the body, primarily in the small intestine and the vagina where they protect against “bad” bacteria that can cause the breakdown of the natural flora of the body. L. acidophilus probiotic is often recommended as a supplement when taking antibiotics. Antibiotics kill bacteria, but don’t differenciate between “friendly” and “unfriendly” organisms, so the balance between good and bad bacteria can be upset. Taking L. acidophilus probiotics help restore the healthy balance of bacteria

The primary dietary sources for L. acidophilus are onions, tomatoes, bananas, honey, barley, garlic, wheat, carrots, rice, garbanzo beans and breast milk among others. It is also found in fermented soy products such as tempeh and miso, which are options for vegans and other vegetarians who don’t consume dairy products, or for those who may be lactose intolerant. Fermented dairy products such as yogurt and kefir are natural sources as well. L acidophilus is also added to milk, which provides a medium for the beneficial bacteria to replicate. Such milk is sold as “acidophilus milk,” “sweet acidophilus milk,” or “probiotic milk”. Acidophilus milk is often thicker than regular milk and has a consistency of buttermilk.

The evidence for using L. acidophilus to prevent diarrhea is mixed. Some clinical research suggests L. acidophilus may be effective when used to prevent traveler’s diarrhea (caused by eating contaminated food). Other studies have found that when taken regularly, it may help prevent gastrointestinal infections in adults. Some people use L. acidophilus to treat or prevent vaginal yeast infections, although evidence for its effectiveness is mixed as well. Additional clinical research in this area is warranted. L. acidophilus has also been suggested for the following conditions, although evidence in most cases is preliminary or mixed:

  • Replacing the “friendly” intestinal bacteria eliminated by antibiotics
  • Helping digestion
  • Suppressing disease causing bacteria
  • Treating chronic constipation
  • Treating symptoms of irritable bowel syndrome and inflammatory bowel disease (such as Crohn’s disease and ulcerative colitis)
  • Immune system enhancer
  • Lowering the risk of pollen allergies
  • Helping to treat high cholesterol

L. acidophilus should be taken only under the supervision of a healthcare provider due to the potential for side effects such as gas, upset stomach and diarrhea as well as interactions with other medications and dietary supplements. People with weakened immune systems ( due to diseases or drugs that suppress their immune system) should

consult their physician. People with artificial heart valves should not take L. acidophilus because of the rare chance of bacterial infection of the valve. Despite these adverse effects, L. acidophilus is generally considered safe for most people. Get emergency medical help if you have any signs of allergic reactions such as hives, difficulty breathing, swelling of your face, lips, tongue, or throat.

L. acidophilus dosing is measured in terms of live bacteria. Adults can safely take between one and 10 billion L. acidophilus bacteria daily which can be taken twice a day or split up into smaller doses throughout the day. There may be a need to taper dosage to establish daily dose to maintain the healthy flora of the intestines or fight bacterial vaginosis without experiencing side effects. Taking daily dose of less than one billion bacteria may not give you the benefits expected from the supplement.

L. acidophilus dosing in children under the age of 18 has not been studied as thoroughly as in adults. Consult a qualified healthcare practitioner before using Lactobacillus acidophilus in children.

L. acidophilus is available in granule, powder, capsule and tablet form. It is also available as a liquid preparation and as a vaginal suppository. Some dairy products, especially milk and yogart, contain L. acidophilus . Refrigerate L. acidophilus supplements for best quality. Some preparations are in a form that does not break down under normal temperatures and may be convenient for travelers who can’t refrigerate their supplements. Check the package label for storage instructions in these cases.



Warfarin (Coumadin)

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Warfarin is the gerneric name for the brandname Coumadin. It is the most widely prescribed anticoagulant in North America. Warfarin is approved by the Food and Drug Administration for the prevention and treatment of Venous Thromboembolism (VTE) as well as for the prevention of thromboembolitic complications associated with Atrial Fibrillation (AF), heart valve replacement and Myocradial Infarction (MI). The dose of Warfarin is patient-specific, based on the desired intensity of anticoagulation and the patient’s individual response (DiPiro, et al, 2005). This life saving medication requires continues patient monitoring and education in order to be effective. As with all anticoagulants, bleeding is the major adverse effect of Warfarin. Prothrombin time (PT), hematoricit and International Normalized Ratio (INR) are laboratory tests that physicians can conduct in order to monitor safe use of the medication (Lacy,, 2005). Also, physicians will thoroughly question the patient regarding their medications. Changes in medications, including changes in dose, as well as non prescription drugs and dietary supplement use will be carefully accounted for.

Do not switch brands once desired therapeutic response has been achieved. There is a significant drug interaction with the concomitant use of vitamin K, aspirin and NSAIDS. These medications considerably affect the use Warfarin and should be monitored carefully. There are other medications (certain antibiotics) and herbal remedies (Gingko, Ginseng and St. John’s Wort among others) that also interact with Warfarin and need careful physician supervision when taken together with Warfarin. If a patient is to undergo an invasive surgical procedure (dental to actual minor/major surgery), Warfarin should be stopped 3 days before the scheduled surgery date and the INR/PT should be checked prior to procedure. This medication should be taken in an empty stomach, same time each day. Do not change dietary habits once stabilized on Warfarin therapy; a balanced diet with a consistent intake of Vitamin K is essential. Check with healthcare provider before changing diet. Warfarin is not recommended during pregnancy because it crosses the placenta and produces fetal abnormalities (Lacy,, 2005).

The safe and effective use of Warfarin can be improved through Medication Therapy Managment services by providing the patient with a structured in depth patient education and comprehensive medication review. Medication Therapy Management services lower the overall cost of care by reducing the frequency of thromboembolic events.