SYLVIA HIGGINS MEMORIAL ESSAY - General Category Honourable Mention, 2006
Richard Schlichemeyer, currently a fourth year Pharmacy student, at the University of Saskatchewan, Saskatoon, demonstrates the valuable communication skills which a community pharmacist would offer to people with lupus. His easy-to-understand essay details the important resources that pharmacists can provide. He plans to pursue a career as a hospital pharmacist and in realizing that lupus is an under-recognized chronic disease, he hopes to increase the profile of lupus as a condition that pharmacists need to be more aware of and involved with.
The Role of the Community Pharmacist on the Lupus Health Care Team
Systemic lupus erythematosus (SLE) or "lupus" is often described as "The Disease with a Thousand Faces". It manifests in so many forms since SLE can target any of the body's tissues. Treating SLE is difficult and requires a health care team to work together to provide optimal care. Members of this lupus team often include a family doctor, rheumatologist, dermatologist, nephrologist, hematologist, immunologist, clinic nurse, psychologist, physiotherapist, dietitian, opthalmologist, and a pharmacist. The pharmacist is an essential member of this team. Community pharmacists are probably the most frequently seen health care professional by the public. Their role on the lupus team is to help detect potential lupus patients earlier and make appropriate referrals, manage and optimize drug therapy, give support and advice, and educate the patient.
While it is not the pharmacist's jo'b to diagnose, he/she has a role in early detection of SLE in patients. When a patient starts to complain of certain symptoms such as joint pain, swelling, rash, and headache to the pharmacist, "red flags" should go up and the pharmacist should interview the patient further. If he/she feels there is something to be concerned about, the pharmacist should recommend that the patient go visit their physician. These symptoms could be due to many other things; they could be harmless, but may be significant. The goal here would be to speed up diagnosis by detecting possible SLE patients.
Lupus patients may need to take a multitude of drugs to minimize symptoms and prevent flare ups of their disease. Variable dose regimens and long lists of adverse effects can be confusing and sometimes frightening to the patient. Fortunately, the pharmacist is a drug management expert. Drug distribution is perhaps the most well known job of the pharmacist by the public, but it is not their only job. The pharmacist has other very important duties such as ensuring the safety of medications, monitoring drug therapy, and giving patient education.
Educating the patient about the disease and the drug therapy is an essential part of a pharmacist's role. The pharmacist can help make sense of the drug therapy by explaining what the drugs do, their benefits, and adverse effects. Certainly just looking at the side effect profile for some commonly used drugs in SLE, such as corticosteroids, would be very intimidating and scary for a patient. The pharmacist should sit down with the patient and explain these adverse effects, his/her likelihood of experiencing them, and how to minimize or prevent them. Emphasis should however not be on adverse effects, but on the benefits of these medications. Education on how a patient needs to take his/her medications is also an essential job of the pharmacist. A patient who has a good understanding of the disease and the drugs used will adhere to therapy better and may develop a more trustworthy relationship with the lupus health care team and what they are trying to do.
The effects of the disease on the patient and the efficacy of the medications are something the pharmacist has to consider. Ultraviolet (UV) light is a trigger factor in some forms of lupus. The pharmacist is able to give advice on UV protection such as sunblock selection and what clothing to wear while in the sun. Lupus also can affect kidney function. The kidney eliminates many types of drugs, so kidney dysfunction could cause certain drugs to accumulate in the body and cause toxicity. The pharmacist needs to be aware of the patient's kidney function and determine if dose adjustments on certain medications are necessary. For example, an SLE patient taking methotrexate who is slowly developing renal dysfunction may have to either adjust his/her dose or discontinue it completely because it is primarily eliminated by the kidneys.
The pharmacist needs to consider what effect the medications used for lupus will have on the individual and be able to react accordingly. Along with the disease, several drugs commonly used in SLE, such as non-steroidal anti-inflammatory drugs (NSAIDs), can affect kidney function. The pharmacist needs to take this into consideration as well. Osteoporosis is an adverse effect of using corticosteroids over a long period of time. The pharmacist is able to give advice on how to prevent bone loss, information on drugs available, and help the patient with product selection for calcium and vitamin D supplements. Corticosteroids can also increase blood pressure. This could be a concern in patients especially for those already with uncontrolled hypertension. The combination of a pharmacist's intervention with home blood pressure monitoring has been shown to significantly improve blood pressure control in patients with uncontrolled hypertension.
Another important job of the community pharmacist is to make sure all of the patient's drug therapy is compatible. For example, making sure the patient is not using any sulfa drugs because these drugs can mimic an SLE flare up in some people. Many drugs commonly used in lupus patients, such as warfarin, can be affected by other drugs or herbals. The pharmacist should identify potential interactions and notify the physician if changes or increased monitoring need to be done. Many lupus patients suffer from other conditions not related to their SLE. The pharmacist must help manage all of the drugs the patient may be taking and help to minimize problems related to drug therapy.
Some patients feel helpless and turn to alternative and complementary therapies to try to cure their disease. According to Wallace, half of all lupus patients take alternative medicines on a regular basis, but may never tell their doctor about it. Pharmacists are often more accessible to the patient and thus make them more likely to be asked about alternative and complementary therapies for lupus. Many herbals interact with common medications used in lupus, have serious adverse effects, and many can flare the disease. By educating the patient about these things, the patient can make a more informed choice. Above all, the pharmacist should emphasize that the patient talk to their doctor about any alternative or complementary therapies they may be thinking about.
Many pharmacies offer specialized programs to help patients with certain conditions or addictions. Smoking can worsen SLE symptoms and put the patient at high risk for heart disease and stroke. Some pharmacies have smoking cessation programs which can help the patient quit his/her habit. Smoking cessation programs often involve coordination with the patient's family doctor and use of medications such as bupropion and nicotine patches. The pharmacist offers extensive advice, counselling, and support to the patient in addition to the stop-smoking aids.
Hyperglycemia is a side effect of corticosteroids and can be troublesome for many patients especially diabetics. Some pharmacists are certified diabetic educators who have special training in helping people manage their diabetes. They can give advice on how to manage the patient's blood sugars while on corticosteroids such as using a blood sugar monitor more often and when to increase their insulin dose (if necessary).
The community pharmacist is a valuable member of the lupus health care team and can greatly impact the care of their patients. Patient education, drug therapy management, support and advice are some of the duties of the lupus team pharmacist. The pharmacist's intervention with an SLE patient will help improve outcomes. This has been demonstrated in other chronic diseases such as hyperlipidemia. The SLE team pharmacist does not just treat the person as a single disease entity. The person needs to be treated as an individual. All treatment is not going to be the same and there will be challenges in every case. Everyone has different circumstances as the disease affects everyone differently. Pharmacists have an essential role in the drug therapy aspect of SLE and offer many skills that can improve patient outcomes and quality of life. As more research is done and advances in therapy come about, the pharmacist's role will be even more important and extensive.