Community pharmacist makes big impact with one small swap

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Nicole Sangalang

“Pete” was on liquid potassium to replace the potassium he was losing due to his blood pressure medication. But when Pete’s insurance plan stopped fully covering a monthly supply, Pete started to ration. He took a teaspoon of the liquid every day rather than the prescribed tablespoon. The results were apparent in his routine potassium monitoring that he underwent with his primary care physician.


“You have to have potassium to make your heart beat,” said Nicole Sangalang, PharmD, Pharmacy Manager at Ralphs Pharmacy in Costa Mesa, CA. Since Pete’s levels were low, the doctor kept prescribing more and more. “I could see he was distressed about this when he came into the pharmacy to pick it up. I pulled him aside to the consultation window so we could talk about it.” 


Sangalang soon learned that Pete had diabetes, and the liquid potassium presented more problems for him than just the price. After talking to Pete, looking at his history, and consulting Pete’s doctor, Sangalang was able to uncover and solve several potentially life-threatening problems for the patient. 


Many people ration medications or otherwise take them incorrectly, and could benefit from medication therapy management with a pharmacist. But as other stories in this series show, this type of service often isn’t covered by health insurance. 


Price, taste of medication


When Sangalang learned Pete had diabetes, she asked about his blood glucose control. “He admitted that it could be better, and that he had no idea liquid potassium would raise it,” Sangalang recalled. “He also really hated the taste of the potassium.” Essentially, the price and the taste of the medication were motivating Pete to take as little as possible.


Searching Pete’s records for any reason he might have been prescribed liquid versus the cheaper, sugar-free pills, Sangalang found nothing. Pete didn’t know why he was on the liquid either. “He was surprised to know it even came in pills and glad that it would be so much easier to take. Pills are easier to count than milliliters.” Sangalang called Pete’s doctor and asked permission to make the switch.


“The doctor happily agreed. He said he was grateful I had taken a look at the big picture and had recommended a therapy that would increase compliance for his patient,” she said.


Soon Pete’s potassium levels were consistent and on target. “That minor change made a big difference,” Sangalang said. “We got his potassium and his sugar under control by switching him to a medication that was cheaper and made him more compliant. And with medicine that’s playing with your heart, we saved him some trips to the emergency room.”


‘Personal health care provider’


Pete now considers Sangalang his personal health care provider. He often calls the pharmacy to ask her for a second opinion on his doctor’s most recent advice. “Honestly, he won’t speak to anyone else but me. He’s always willing to share what’s going on with his health and asks how he can improve it.” 


Sangalang wishes she could spend more time with all the patients who are misusing their medications. “Just yesterday, I had another patient who was doing the same thing—rationing her medication. She was cutting her estrogen patches in half to make them last longer.”


In a health care system that fragments care across numerous specialists by design, Sangalang sees a clear role for pharmacists.


“Patients get specialty care from several providers at any given time, and the communication between these providers is usually nonexistent,” she said. “It’s like a puzzle and the pharmacist is in a position to be the glue that holds all the pieces together. Without that glue, the puzzle ultimately falls apart.”



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