It all began as a typical medication adherence call that quickly became an interprofessional intervention and coordination of care regarding our patient’s statin therapy.
The call began with inquiring about the patient’s statin therapy (Simvastatin 40 mg) to ask if she was still taking it and then how she was doing on it . She happily reported that she was “tolerating the medication well and was not experiencing any side effects”. We continued the conversation by sharing some potential side effects of the medication and encouraging her to share with her health care provider if she experiences muscle pain or weakness in her legs. She shared that she had in fact had some cramping/leg pain. The patient explained how she had been experiencing these pains in her legs at night to the point where she wouldn’t even know “where to lay her legs”. The patient ended the call asking for a recommendation for an over-the-counter product for her knee pain. I shared that I would look into some options for her, discuss with my preceptor and call her back, which she was delighted to accept.
When we called our patient back, she immediately knew who was calling and excitedly exclaimed “Elena!”. It was rewarding to hear that she remembered my name and that she was delighted to hear from us. The purpose of the second call was to receive permission from her to reach out to her physician to request a therapy change for the simvastatin to a different statin. She agreed and provided us with her provider’s name and contact information. Before the end of the call, she was grateful we had been so helpful so she asked one more question regarding over-the-counter medications.
She asked if there was an over-the-counter medication that could help her heart rhythm specifically to “shock her back into rhythm”. She explained that she was diagnosed with atrial fibrillation (a-fib) and was taking medications for it but was feeling like she was “in and out of rhythm”.
As an intern, I responded in a similar manner as the first call expressing that we would look into her question further and reach out to her with the information we collected. In addition, we noticed her medication profile only had two medications listed, but the patient mentioned another medication, so we asked for her full medication list and pulled from her dispensing profile as well:
Metoprolol Succinate ER 25 mg, take one tablet by mouth daily
Diltiazem ER 180 mg, take one capsule by mouth daily
Eliquis 5 mg, take one tablet by mouth twice daily
Losartan Potassium 50 mg, take one tablet by mouth daily
Simvastatin 40 mg, take one tablet by mouth daily in the evening
After reviewing the patient's medications further one interaction stood out to my supervising pharmacist, Dr. Pezzino. We immediately recognized the Adverse Drug Reaction - Drug-Drug Interaction of diltiazem ER 180 mg and simvastatin 40 mg that can increase the concentration of the simvastatin and concurrently decrease the concentration of the diltiazem. Which could increase the risk of the muscle pain side effect associated with the statin and decrease the rate control from the diltiazem. Additionally these two medications were prescribed by two different providers – a cardiologist and primary care provider.
Shortly after, we contacted the patient’s providers' offices to share an updated medication list, the interaction and recommendation. We reached the nurses line. We explained the situation, including the side effects the patient was reporting, the nature of the interaction, and our recommendation to discontinue the simvastatin and initiate rosuvastatin 10 mg. We also encouraged the provider to schedule a visit with the patient given her request for her a-fib. The nurse forward the message to the provider and the call was concluded. The provider accepted our recommendation and promptly sent in a new prescription for rosuvastatin 10 mg, take one tablet by mouth daily, and it was filled the following day!. Everyone involved was so excited to see that the prescriber acknowledged our message and accepted our medication therapy recommendation.
She picked up the new prescription for the rosuvastatin 10 mg the following day. We called to counsel her on the new medication, we explained to stop the simvastatin and start taking the rosuvastatin daily moving forward. Along with that we let her know that hopefully with this new therapy the side effects she was experiencing would begin to subside. During the call she told us that her provider called to check in on her, explain the new medication, and schedule an appointment for the next week! To end the call I asked if she still needed a recommendation to help with her knee pain and responded yes and that she would come in the next afternoon to talk with me about a recommendation.
We contacted her for a follow up after two weeks. She was excited to pick up the phone and hear from us again! When asking how she was doing with her new medication she was pleased to share that she was doing great and let us know that she has not experienced any leg discomfort since switching to the rosuvastatin! We were so thrilled to hear that, it is amazing the impact of following-up and truly caring for a patient can make a difference in a patient's life. To close the circle on this interaction we provided a recommendation for her arthritis-associated knee pain. We were able to suggest Voltaren Gel, which she had not tried before, and counseled on the proper usage. Following the call we collaborated with the pharmacy team to leave a note about our recommendation that can be given to her the next time she picks up at the pharmacy.
After interacting with this patient over a two week time span I was able to truly see the impact interprofessional collaboration, patient follow up and the importance of the pharmacist-patient relationship can have on someone. Coordinating care and being consistent with follow-up between physician and pharmacy teams while checking in on our patients can generate positive outcomes in someone's therapy and overall quality of life.
Written by:
Elena Patestos
Wilkes University Pharm D. Candidate 2023 (Community APPE Rotation at Weis Markets in Schnecksville, PA with Nicole Pezzino and Isabelle Litvak)