Lupus — a real trial is held this time
Pharmacists need to increase their involvement in patient care activities, says an October report from the Health Care Financing Administration (HCFA).
According to the American Society of Health-System Pharmacists (ASHP), evidence shows that pharmacist involvement in patient care teams has a positive impact on patient outcomes and reduces adverse drug reactions. However, pharmacists need to increase and broaden that level of involvement to better the health care state of the nation, the HCFA report says. (See www.ashp.org/public/news/ShowArticle.cfm?id=1754 for further information.)
What follows is the description of a patient with systemic lupus erythematosus (SLE) who might have had better outcomes along her journey had she experienced top-quality pharmaceutical care.
Case: Stacey is a 33-year-old woman. In 1989, she took an oral antibiotic — which one she does not recall — for a sinus infection. Shortly after that, when she was 22, she was diagnosed with lupus nephritis.
"My doctor said it was probably due to the antibiotic," Stacey tells Drug Utilization Review. She was treated initially with prednisone. "It really puffed me out badly," Stacey recalls.
Following her diagnosis, Stacey was started on cyclophosphamide (Cytoxan). Her current medications include erythropoietin (Epogen), warfarin (Coumadin), calcium acetate (PhosLo), labetolol, potassium (K-Dur), and zolpidem (Ambien).
Stacey has had numerous blood clots and suffered a heart attack in 1996. The following year, Stacey spent three weeks in the hospital with severe gastrointestinal pain that remains undiagnosed. During that time, however, she lost most of her hearing, presumably due to nerve damage caused by the lupus.
"The nurse came into my room at 4 in the morning. It was very scary to open my eyes and see her mouth moving, but not hear her voice," Stacey recalls. Stacey now has lost all hearing in her right ear and has only 20% hearing in her left ear. "The nurse thought I lost my hearing as a result of taking too much pain medication, but the doctors said it was from the lupus," Stacey says.
Throughout this time, Stacey’s renal function continued to decline.
"I started peritoneal dialysis on Jan. 24, 1998," Stacey reports. "I’m on Epogen 8000 units three times a week now. I used to have someone who came to the house to give it to me, but now I have to inject it myself into my hip."
She says that her most recent lab values showed a hematocrit of 20%. When asked if she can tell a difference after she takes her erythropoietin, Stacey replies, "I can tell a difference. Without Epogen, I feel worn out. My legs hurt like I’ve just finished exercising hard. After an injection, I definitely feel better. I start to feel more energetic."
Stacey seems to take her dialysis in stride, careful to watch her fluid and salt intake. She’s now been on the waiting list for a kidney transplant for two years.
"The average length of time on the list is 2½ years," Stacey reports. "But some people have to wait a much longer time than that before being matched for a kidney. I’m almost to the point now where I’ve completely stopped making urine," Stacey says. "It’s a weird feeling not to have to use the bathroom several times a day."
Despite this history, Stacey has a positive attitude. She makes monthly visits to her nephrologist and his associates, whom she describes as "the nicest bunch of people." She married in 1996 and is happy with her life. "Of course, I’d like a new kidney," she’s quick to add.
With early intervention from a pharmacist, Stacey’s lupus might have been prevented. With intervention now, her quality of life can be improved and future errors potentially prevented. Stacey’s case is one that nearly begs for the intervention of a pharmacist. It also begs the following questions:
• Was the initial antibiotic prescribed for Stacey’s sinus infection the cause of her lupus? Was the antibiotic necessary? If necessary, was it the best choice of antibiotic for her? Was the antibiotic dosed and dispensed correctly?
• If Stacey’s hearing loss was related all or in part to the pain medications she received during her three week hospital stay in 1997, could closer care by a pharmacist have prevented the hearing loss through exercising better watch of her pain medication regimen?
• Without having access to Stacey’s medical record and thus knowing the details of dates of blood clots and initiation and dosing of warfarin, could her heart attack in 1996 been prevented by the close monitoring by a pharmacist of her INR?
Pharmacist counseling lacking
Although she certainly has benefited from pharmaceutical expertise of hospital pharmacists filling her inpatient prescription orders, Stacey has never had a clinical interaction with a pharmacist. Because most of her outpatient medications come to her via mail-order pharmacies, she doesn’t benefit from pharmaceutical care opportunities with regular refills. She reports that, up to this point, when she goes to a pharmacy for a new prescription, she never bothers the pharmacist to ask questions "because they always look so busy." At this pharmacist’s urging, Stacey will now feel free to ask questions and to ask them of the pharmacist. At her next visit to the nephrologist, she will inquire about NESP, Amgen’s new formulation of erythropoietin that can be dosed just once weekly.
When Stacey receives her kidney transplant, she may finally enjoy in-depth clinical consultations with pharmacists who will dutifully walk her through her new drug regimens and help keep her safe.
"With all the training and knowledge that pharmacists have," Stacey comments, "It seems like they should be on the floor more, interacting with patients, instead of behind the store counter filling prescriptions or hidden in a room somewhere in the hospital."
Note: When asked if DUR could print her contact information, Stacey readily agreed, willing to exchange some of her privacy for the advice or suggestions of help that might come to her from readers.
Source
Stacey Givan, 16001 Slater Ave., Belton, MO 64012. Telephone: (816) 331-4640.
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