By Carla Rubingh, Pharm.D
Pharmacists today can play many different roles in patient care. The most familiar type of pharmacist is the person who dispenses your medication at your local pharmacy. A newer phenomenon is the clinical pharmacist, who sees patients in interdisciplinary clinics and physicians' offices. Both types of pharmacist can contribute to your treatment plan.
Clinical pharmacists, who may have additional training beyond that required to be a dispensing pharmacist, review patients' current and past medication regimens. The pharmacists then work together with physicians and other providers to tailor therapeutic plans. Clinical pharmacists are most often found in clinics associated with universities and colleges of pharmacy.
All pharmacists are trained as medication specialists. They are not trained to diagnose diseases, but they are educated in the various treatments of specific diseases. Both dispensing and clinical pharmacists can help your physician avoid drug interactions and side effects, and they also may be able to provide information about potentially useful therapies. Pharmacists can be especially helpful to patients with multiple conditions, even identifying medications that may be helpful for more than one problem. With the many challenges in fibromyalgia treatment, pharmacists are key resources for your health care.
About the author: Dr. Carla Rubingh is a clinical pharmacist at the University of Utah Hospitals and Clinics, specializing in pain and headache management. Dr. Rubingh completed her doctor of pharmacy degree at the University of Nebraska Medical Center, and went on to complete a residency at the University of Utah. She is involved in several state and national pharmacy organizations and has been a speaker at local, state and national events.
Dr. Rubingh Answers Readers’ Questions:
Q: Since coming down with fibromyalgia, I seem to be having more adverse drug reactions than before. Any thoughts on how much of this is due to the nature of this specific condition, or to being chronically ill in general?
A: One of the theories about the pathophysiology of fibromyalgia involves an increased sensitivity to medications and possibly foods or environment. However, we also do sometimes see increased sensitivities in people with other chronic illnesses. Sensitivities also could be purely medication-related. Some pain medications can increase histamine release, making people more sensitive to adverse reactions. So, it could be any of the above or none of the above. I would recommend starting medications at low doses and increasing slowly to improve tolerability.
Q: Are there any particular drug reactions or interactions that you see often in fibromyalgia patients? (I know that not everyone will react in the same way, but it is helpful to have an idea of when trouble might occur.)
A: In my experience, fibromyalgia patients are more sensitive to the central nervous system effects of medications, such as drowsiness and fatigue. Medications with a high probability of these side effects should be started at low doses and increased slowly.
Q: Recently I have read about rebound headaches being caused by taking OTC and prescription painkillers. Is there any concern like this for fibromyalgia pain treatment?
A: With all pain syndromes there is a concern about the use of short acting opioids and the "roller-coaster effect" (meaning that the medication is absorbed, pain is relieved, medication wears off in several hours, and the cycle continues). More time is spent "chasing" pain. However, I am not aware of any concern for rebound type pain in fibromyalgia patients taking pain medications.
Q: Can you offer any guidelines on how to identify and/or avoid adverse drug reactions and interactions?
A: The best recommendation I can make is to get all your prescriptions filled at one pharmacy. All pharmacies are equipped with computer screening programs to notify the pharmacists of potential interactions. They can then make clinical judgments concerning the probability and seriousness. Also, make sure that your doctor knows everything that you are taking, including over-the-counter medicines and herbal supplements.
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Q: How common is it for pharmacists to be knowledgeable about supplements — their effects and interactions with drugs?
A: It is extremely variable. Most colleges are now offering classes about herbal products. Literature and educational materials are readily available and contain more and more information on herbal supplements.
Q: I take so many medicines and supplements that I need a list to review with physicians and pharmacists. Do you have any examples of effective formats for such a list? (My list includes: drug/supplement name and manufacturer; dosage and time taken; reason for taking and result; prescribing doctor. Is there anything else I should include?)
A: I think this sounds like a very good format. It is commendable for you to keep such an extensive list and play an active role in your care. Maybe adding a section about side effects would be helpful.
Make sure you are documenting any effect a medication had. Sometimes there are medications that have a similar mechanism of action that may not cause the same side effect. It is important that your physician know even if something was just somewhat effective.
Q: Are pharmacists most comfortable talking to patients or to physicians about possible contraindications or interactions? Are there laws, regulations or professional ethics that guide this process, and do they differ for dispensing pharmacists versus clinical pharmacists?
A: All pharmacists follow the same laws and regulations. I would guess that most pharmacists are comfortable talking to either the patient or the physician. If the drug-drug interaction is significant or there is an absolute contraindication for the use of a medication that has been prescribed, they should contact the physician.
Q: How can I get an appointment with an outpatient clinical pharmacist? Can I get such an appointment directly, or must I arrange this through a physician? (There are none associated with my doctor's practice.) Does insurance typically cover these appointments?
A: Appointments are arranged through a physician. Most insurance companies do not cover this referral. Most clinical pharmacists are associated with universities and colleges of pharmacy.
Q: Is it important to let your physician know who your pharmacist is, and which pharmacy you use?
A: Some physicians will value this information, others will not. It is important to have the name and phone number of your pharmacy included on your list of medications that you carry with you.
Q: Is there a reputable online source for information on drugs and potential side effects/benefits?
A: The National Library of Medicine's medlineplus.gov site has drug information from MedMaster, a product of the American Society of Health-System Pharmacists, and the USP DI(r) Advice for the Patient, a product of the United States Pharmacopeia. I think these are very good sources of information. I would advise checking with at least two sources.
Q: Are there recommendations for timing of taking drugs, vitamins, and other supplements? For example: anti-inflammatory drugs, typical multivitamins, calcium supplements, and antidepressants – can these all be taken at the same time or do they need to be taken at different times?
A: Sometimes recommendations do exist for timing of medications. Usually this is based on possible side effects, for example drugs that cause insomnia should be dosed in the morning. The medications that you mentioned can be taken together. Anti-inflammatory medications should always be taken with food. Thyroid supplements are often overlooked, but these should be taken on an empty stomach and not at the same time as vitamins containing iron or calcium supplements.
Source: The Arthritis Foundation (www.arthritis.org).