Look beneath the tip of the iceberg

A case example Feb 2021 80-year-old female presents to your pharmacy with excruciating pain in her left big toe, swelling, redness and inflammation. She is standing in the pain reliever section of your pharmacy, a tube of OTC Voltaren rub in her hand. She requests a pharmacist consult, so your staff ask you to speak with her. She says that the pain started last night, and she wasn’t able to sleep. The pain is so bad she can’t put on socks or shoes. It has happened to her before once in the past year or so, and was told it was gout, but did not treat it. Now, the pain is unbearable. She has tried acetaminophen 1g by mouth for two doses with no improvement of symptoms. Upon further questioning, you rule out any fever, she has no ingrown or hanging toe nail infection, fever or chills. The patient did not stub her toe. She does have feeling in the toe. She reports she is on Pantoprazole 40mg daily and Olmetec plus (Olmesartan 40mg/Hydrochlorothiazide 25mg) 1 tablet daily. She has no history of heart attack/stroke, no history of stomach issues or ulcers, no issues with her kidneys that she is aware of. She has GERD and hypertension. You advise her that Voltaren will not be helpful, and recommend Ibuprofen 400mg, 2 capsules every 8 hours for 3 days with food. You advise on importance of continuing Pantoprazole to prevent stomach issues. You also advise her to see her family doctor if no relief or if pain worsens after two days. Patient is appreciative, purchases the Ibuprofen, grabs a card, and leaves. March 2021 One month later, you are checking a prescription for the same patient for a diagnosis of acute gout in the left big toe made by the doctor at the walk-in clinic. It turns out her family doctor is out of town and has been de-rostered as a result. She came back to you because she appreciated the service. The prescriptions read as follows, which you find appropriate and dispense: Prednisone 30mg by mouth daily for 5 days – to fill now Indomethacin 50mg by mouth three times daily for 5 to 7 days – to have on hand for recurrent acute gout attack You counsel the patient on gout risk factors, including dietary factors such as: seafood, red meats, alcohol, fructose drinks, as well as conditions such as CKD and obesity. She reports that she does not eat much of those foods, despite being overweight. You advise the patient that she would likely benefit from gout prophylaxis and updated blood work. The patient reports that the walk-in clinic doctor did give her a requisition to get blood work done. June 2021 Patient presents again with the same issue, acute gouty arthritis of the left big toe. This time, she saw a different walk in clinic doctor who wrote a prescription for the following, which you deem appropriate and dispense: Colchicine 0.6mg, take 2 tablets by mouth now, then take 1 tablet 1 hour later, then 12 hours later take 1 tablet twice daily for the next 3 days Upon further questioning, the patient reports the doctor chose colchicine because her previous blood work showed reduced kidney function (hence no NSAIDs), and prednisone was hard on her stomach. You ask the patient to wait, and take a look at the blood work ordered in March 2021: March 30, 2021 b/w: total cholesterol @ 5.74, triglycerides @ 2.05, HDL @ 1.42, LDL @ 3.38, non-HDL @ 4.32, A1c @ 5.7%, electrolytes WNL, CBC WNL, SCr @ 121, eGFR @ 37 (trending this way, last reading in 2019 also similar) You conduct a 3-serial blood pressure check in the pharmacy as well: 132/71, HR @ 76. You speak with the walk-in clinic doctor and request updated blood work, specifically including: uric acid levels, renal panel, electrolytes and CBC, to which the doctor agrees. You give the req. to the patient. Results: June. 15, 2021 b/w: SCr @ 113, eGFR @ 40, urate @ 453 (150-390), electrolytes WNL, CBC WNL. You phone the patient, and request she see the doctor for reassessment and discussion of blood work. You recommend the following to the doctor after discussing the potential plan with the patient and advise her that recurrent gout is likely a combination of her elevated uric acid levels and her CKD: 1. Initiate allopurinol 100mg po daily for chronic suppression of gout 2. Continue colchicine 0.6mg, 1 tab po q other day x 3-6 months during inter-critical period of gout to prevent flare while initiating allopurinol Two weeks later: b/w again for renal panel and LFTs post allopurinol and colchicine initiation AND 3. d/c HCTZ --> thiazide diuretic that can cause hyperuricemia (spoke with pt and diet is not a risk factor here as she does not eat seafood, does not drink alcohol much, no fructose, no heavy eating on red meats), advised likely based on b/w and CKD 4. Initiate amlodipine 5mg, 1 tab po daily for BP to replace HCTZ, with a target systolic 3.5 and non-HDL >4.3 AND CKD) MD and patient agree. Six months later, as of Dec 2021, patient has not had a gout attack and her blood pressure is stable at 115 systolic. You have initiated compliance packaging to ensure adherence. The cardiologist also phones to appreciate you starting her on the SGLT-2 inhibitor and statin. The need and the opportunity Redundancy in our healthcare system, in certain aspects, is actually a good thing. This is why it is important for pharmacists to check their patients’ blood work routinely and make recommendations to their prescriber as necessary and relay this to the patient and/or (in provinces that are much more progressive than Ontario) initiate drug therapy as indicated. It’s also essential to monitor your patients to improve their quality of life and enhance outcomes. There are many patients walking around with undiagnosed, yet treatable, conditions. Through our vigilance, we can catch these conditions before they become more complicated and lead to worsening outcomes and unnecessarily increased costs to the healthcare system. To do this we just need: 1. Clinician collaboration 2. The appropriate utilization of healthcare specialties (pharmacists as drug experts, prescribers/lab requisition authority) 3. Fair stakeholder remuneration for services (e.g. government being on board with policy changes to allow for this to happen).

Reality-Based Medicine

Look beneath the tip of the iceberg

Register for free access or login.

Blog Author

Samier Kamar