Many of us who are HIV-positive focus on finding the perfect doctor; someone that we feel comfortable with, form a good working relationship with and develop a sense of trust with over time. Butr how many patients have taken the time to develop that same relationship with their HIV pharmacist?
A new study out of Michigan along with several other studies have found that the pharmacist-patient relationship might just be the most important relationship within the healthcare chain, even more important than the physician/patient link. Not only can a certified HIV Pharmacist help manage all of your medications, reduce the risks of medication errors and interactions, but they are an effective tool in keeping the costs of your care down, while optimizing your medication regimens.
For this article I will be referencing two studies. The first is an American study that is somewhat limited in scope, but is very recent. It is a September 2017 study by Michelle Sherman, RPh, FASCP, FACA, AAHIVP and President of MichRx Pharmacist Consulting Services Incorporated. Her Study can be found here.
In looking at the first study group, the first item that I noticed is that the total enrolled patient group was small, in that a total of only 58 patients were enrolled. However out of those 58 patients, a very large amount of positive data was gathered. This study was an 18 month intensive study, with a total of 471 interventions that occurred between the patients and their pharmacist. 330 of these interventions were daily clinical care documentation, assessments of medication adherence and laboratory values/data monitoring. The remaining 141 interventions were pharmacy interventions for items such as HIV medication education sessions, adverse drug reaction counseling, smoking cessation counseling, insurance issue counseling, patient referrals, social work assistance, administration of immunizations, and various other pharmacy practice areas.
The study data shows that nine patients in this care model were actually able to decrease the number of medications they were taking, compliance was up substantially and one patient out of the 58 enrolled was actually saved from a fatal drug-drug interaction that was prescribed to them by their physician.
So what are some of the positive goals to come out of this study?
First and foremost, the elimination of a preventable adverse medication interaction that would have 100% resulted in the patient’s death is a positive outcome. Secondly, the measureable rates of total medication compliance were exceedingly high, running in the mid to high 80% range. Third, I would point out that patient satisfaction scores were very high, which relates to a continuing positive relationship with the pharmacy care provider which drives medication compliance and the use of the pharmacist as a member of the overall care team.
Costs per patient as related to pharmaceuticals were reduced which is also a positive net effect, as this allows resources to be re-allocated to other patients who might be in need of other more advanced therapies while still ensuring that the patient at hand is having all of their needs met and has achieved viral suppression and optimized pharmaceutical management. So by working with the pharmacist, the patient benefits, the physician benefits and the funding source (be it a universal payer or a private funding source) benefits.
The second study is a Canadian study published in the March/April 2012 Canadian Journal of Hospital Pharmacy. The article can be found here.
In viewing the second study there are twenty-five areas that the authors identify where an HIV Certified Pharmacist can be of importance in the care of the patient and an invaluable resource to the entire healthcare team. I am going to highlight some of the key areas where the authors feel that the pharmacist plays an important role, however I strongly encourage you to read the entire article.
Selecting and Reviewing Therapy - The pharmacist is the go-to resource on new medications, both those that have been recently licensed and those that are in clinical trials and under investigational status. Pharmacists work closely with physician researchers, drug clinical trial programs and even pharmaceutical manufacturers to keep abreast of what is new and what is in the pipeline for release. Pharmacists are also experts at optimizing pharmacologic therapies. In addition the pharmacist has excellent working knowledge of all available therapies that are currently available on the market. By working with the clinical pharmacist, the physician or other clinical practitioner can optimize the therapy to the individual patient’s care plan. This is very important when it comes to the issue of managing side effects. One of the barriers to sustaining medication adherence is side effects. By managing side effects (which may include switching therapies to a different medication if determined by the practitioner to be in the patient’s best interest) the pharmacist can ensure that the patient will be compliant in taking their medications.
Pharmacists understand resistance factors, and can counsel patients on the importance of medication compliance and can work with physicians to select new treatment regimens if a failure in treatment occurs. This fact just cannot be overstated. Education is key in this matter, especially in patient counselling programs related to medication adherence programs, side effect management and explaining how missed does of medications lead to drug resistance. Pharmacists should be involved in medication planning discussions with physicians after a patient has had a medication failure.
Pharmacists can manage drug interactions and side effects-working with your physician the pharmacist can help you deal with any side effects, and can help your physician select a different medication if there are any drug-drug interactions. In the end we are all human beings and our bodies react in different ways. A good HIV pharmacist can help to custom tailor a medication program that works for you, not against you.
Working with Complimentary or Alternative Medicines - Herbal medication usage is on the rise, with many studies now placing 65 to 70% of HIV patients taking some form of nutritional supplement, vitamin, herbal supplement or exercise related supplement. However what we also know is that many of the over the counter vitamins/supplements, nutritional supplements and herbal remedies can affect the efficacy of HIV medications. In the study one example is cited where an individual had a total treatment failure as a result of taking Gingko Biloba, a common over the counter herbal remedy used by many for memory or concentration effects (not endorsed by any government agency). Certified HIV Pharmacists are trained to look for and counsel patients on these interactions and can work with patients on safe alternatives.
General Promotion of Health Maintenance - Pharmacists can ensure that patients are up to date on immunizations, watching their diet, maintaining medication compliance, and can provide counseling on personal health, smoking cessation and other areas within their scope of practice. Many HIV patients do not realize that many of the over the counter medications that are readily available in their pharmacy could interact with their medications. In addition, your HIV specialty pharmacist is familiar with some of the issues that we face on a daily basis such as higher cholesterol levels, issues with dry mouth, kidney stones, sexual dysfunction and other issues. Many HIV patients also have a problem with seasonal allergies , and there are ongoing studies investigating these links. Your pharmacist can counsel you on appropriate ways to manage these issues.
Pharmacists can tailor therapies to specific patient populations, such as women, pediatric patients, patients with comorbidities, indigenous populations and patients with hepatitis. I think that the study does a much better job detailing the role of a pharmacist in assisting each of the populations mentioned here, so I will suggest that you read the study and pay special attention to sections 2.1 through 2.4.
Working with marginalized patient populations - This is an area where pharmacists can make a huge impact. Patients with substance use issues should be encouraged to make a comprehensive list of the non-prescribed medications that they are taking to their pharmacist and be treated in a supportive, non-judgmental manner. It is critical for pharmacists to screen for drug interactions between prescribed medications and the street drugs that the patient is taking. Illicit drug use should never preclude a patient from receiving effective HIV medication therapy. Many patients do not have access to refrigeration to store their antiretroviral therapy, therefore it is important for the pharmacist to work with the health care provider to make arrangements to help the patient on to a regimen that works to fit the patient's needs.
Immigrant and Indigent Patient Populations - Pharmacists must be culturally sensitive and understand the barriers to care that these patient populations face. Patient translation services as well as patient assistance programs are available. The authors of this study do a fantastic job in discussing this matter further.
Patient Counseling and Education - This is the area where the authors and I both agree that a well-trained and competent HIV Pharmacist can make a world of impact. Patient medication counselling, compliance counselling and education about medication side effects, adverse reactions, dosing instructions, proper ways to take medications and a host of other discussions should occur with each patient in a private setting that makes the patient feel comfortable. Printed educational materials, support group information and other reference materials are valuable, as well as the business card to the pharmacist so that the patient can contact the pharmacy with any questions at a later date. Medication adherence issues should also be discussed at this time, and text messaging, telephone medication reminder applications or other systems can be set up during this counseling session.
Adherence Issues - It cannot be stressed enough about the role of the pharmacist in educating the patient on the importance of educating the patient in taking their medications as directed on a proper schedule. Please see section 3.2 of the study for an in-depth review of the rather long list of factors and considerations that play into this fact.
As you can see, the role of the HIV Specialty Pharmacist has evolved from that of simply the dispenser of medications into that of a vital member of the care team. In many ways the patient will have access to their pharmacist before they can reach out to their HIV specialist.
Patients should use them as the valuable partner in the health care chain that they are, and recognize that the pharmacist is vital to their success in staying healthy.