Pharmacists: Never Miss An Opportunity to Counsel

April 13, 2020

“I had been practicing for 4 years at that time and longed for the day that pharmacists would have input in patient’s pharmacotherapy. That day is here!”

Thirty-five years ago, I was working outside in my yard when a local physician came to pay me a visit. He started out telling me that I was young and new to the health care system, and that he realized that pharmacists were getting into patient counseling. He told me he was irritated that I was counseling his patients about the adverse effects of medications. He told me about a 60-year-old patient he had who was on long-term prednisone therapy for allergies. I had the “audacity to scare” this patient by telling him that prednisone could “cause stomach ulcers and possibly type 2 diabetes.” I confirmed that I did inform the patient of my concerns about long-term prednisone therapy for allergies.

About 2 months later, I filled a prescription for ranitidine (Zantac) for this same patient; less than 6 months after my warning, the patient was started on NPH insulin. I had been practicing for 4 years at that time and longed for the day that pharmacists would have input in patients’ pharmacotherapy. That day is here! Now, I have physicians not only taking my advice, but seeking out my advice. Physicians and physician assistants frequently call me to ask for alternative therapies.

Recently, we had a prescription rejected for rifaximin (Xifaxan) for a patient who was discharged from the hospital on thiamine 100 mg, folic acid, and a multiple vitamin. I went out to talk with the patient’s husband and discussed his wife’s serious condition. I told him that rifaximin was approximately $2500 per month and would need a prior authorization.

I printed out a flyer from a presentation I created on hepatic encephalopathy. I told him that lactulose syrup would be the next best option. About an hour later, I received an electronic prescription for lactulose 15 mL twice daily from the patient’s physician. I spent at least 10 minutes that I didn’t have educating this patient’s husband about the use and adverse effects of this medication. He left grateful that I took so much time and provided him with measuring devices needed for accurate dosing.

Forty years ago, when I was in pharmacy school, a friend of mine told me that his dad, who was a pharmacist, was told by a physician in the 1970s “you sell the toothpaste and [leave] the prescribing to me!” When I see how far this profession has come, I never lose sight of where I want this profession to go. It only makes sense to me that getting paid for our knowledge and patient counseling skills is most appropriate. That is something I never would have envisioned back in 1985.

I always offer this advice to students I precept: “When a physician asks you a question, don’t pull out your phone.” Physicians have already checked the most common data bases. Know the drugs needed for patients with alcoholism and post-bariatric surgery. Consult the prescriber to remove those di-peptidyl peptidase 4 inhibitors from patients using glucagon-like peptide-1 drugs. Make sure the lisinopril has been stopped for 36 hours before starting sacubitril/valsartan (Entresto). Don’t play “gotcha” when advising a prescriber; we all have our knowledge base and should be respected for the breadth and depth of what we know.

This 61-year-old pharmacist wants this profession to continue its direction in being a major decision-maker on the health care team. Oh, and I’ll sell the toothpaste too-and make sure it is free of pyrophosphates, which can cause gingival irritation; I’ll never miss an opportunity to counsel a patient!

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