Your Guide to Managing Multiple Medications with Pharmacist Mandy Leonard

Podcast Transcript

Cassandra Holloway:  Hi there. Thanks for joining us. You're listening to the Health essentials podcast brought to you by Cleveland Clinic. I'm your host Cassandra Holloway.

Today, we're broadcasting virtually as we are practicing social distancing during the coronavirus pandemic. We're joined virtually by Cleveland Clinic pharmacist, Mandy Leonard. Thanks for taking the time to speak with us today.

Mandy Leonard:  Thank you for having me.

Cassandra Holloway:  Today, we're going to be talking about managing multiple medications because it's important to make sure that you're taking everything safely and making sure that your medications don't interact with one another. So we'll be providing listeners with advice on keeping your medications organized, as well as providing helpful tips when it comes to labels and refills. Before we dive into all of that with Mandy, we want to remind listeners that this is for informational purposes only and does not replace your own doctor's advice.

So, Mandy, I first want to start off by asking you how you're doing during this pandemic and in all these crazy times and if you'll tell us a little bit about your current role at Cleveland Clinic.

Mandy Leonard:  Well, thank you so much for asking how I'm doing. It's been interesting as a pharmacist here at Cleveland Clinic during these COVID times and just making sure that we can take care of our patients and keep everybody safe. So thank you so much for asking that.

My role here at the Cleveland Clinic, I've been here for 22 years as a practicing pharmacist. My main responsibility is to work with the different healthcare providers, such as the physicians and pharmacists, evaluate medications and see what we're going to use when a patient is admitted to the hospital or when a patient comes to one of our outpatient areas and maybe receives an infusion of a medication or even something like a vaccine.

Cassandra Holloway:  So let's dive right in here to this topic, what are the risk factors when someone is taking multiple medications? Why is this important for someone to be aware of?

Mandy Leonard:  Yeah. So the first thing as a pharmacist that I think about is when patients take multiple medications, there are a couple of things, but the top thing that comes to mind is just drug interactions. So it's very important, as a pharmacist, to be able to evaluate that and educate our patients about it. So multiple medications, drug interactions, definitely number one on my list. It's really important that patients know all their medications and keep track of that, and then that way, when a new medication is added, they can make sure that they let their physician know all the medications that they're on. And then as a healthcare professional, either your physician or pharmacist, would be able to tell whether or not there's any interactions that would happen.

Cassandra Holloway:  I'm curious, do you have any examples of maybe common errors or drug interactions that you see on a day-to-day basis?

Mandy Leonard:  So I don't know if there's any more in common, but ones that I think about may be typical for patients would be when let's say you have an infection or you're not feeling well, and a doctor puts you on an antibiotic. We want to make sure that there are certain antibiotics that when taken with certain vitamins, such as even calcium or iron, what happens is, is that calcium and iron can bind to that antibiotic and it makes it less readily available when it's in your stomach to be absorbed. Really when you're on an antibiotic, you want to really make sure that we take it for an extended period of time and exactly how it's taken. So that's one of the things that I'll definitely look out for.

There are other things that might happen with the way drugs are, what we call, metabolized in our body, so how does our body work with those medications and how they are metabolized by our liver. Sometimes two drugs may compete for metabolism in our body, so therefore you might get more of one drug than another, and that could cause side effects. So that's what your physician and pharmacist are going to be looking for when patients are on multiple medications.

Cassandra Holloway:  You mentioned vitamins, so I want to ask you specifically about vitamins and supplements because I feel like many people might not necessarily think of those as interacting with prescription medications. What advice do you have for managing vitamins and supplements or maybe just over-the-counter medications? Should you be asking your pharmacist or your doctor about how these OTC medications interact?

Mandy Leonard:  Yeah. So that's a really good point so thank you for bringing that up. So when a patient, no matter what type of medication they're on, whether it's a prescription medication or what we call an over-the-counter, or OTC, that you don't need a prescription, or even what we would consider a dietary supplements, say ginseng or St John's wort, or something like that, some herbal type of supplement, any of those can interact together. So we can have drugs that are prescription drugs that interact together, we can have interactions that occur between over-the-counter medications and prescriptions, and we even know that herbal supplements as well have some interactions with medications. So I think the key point is that for patients, you need to keep an updated list of everything. That includes prescription, over-the-counter, and then any dietary supplements.

Today with all the technology we have, if people are comfortable, maybe that's just a note that you keep on your phone, that whenever they say, "What medications are you on", but they don't specifically ask you whether it's prescription or over-the-counter or a dietary supplement, you can show them your note page on your phone. Or if sometimes people like to still write it down and that's completely fine, maybe just keeping a list in your purse or your wallet so then that way, if you see multiple providers, you can make sure that those multiple providers know.

But here at Cleveland Clinic we're lucky because we have My Chart, where if you continue to go to Cleveland Clinic provider, we have access to all that information, but that may not always be the case. And so you may go see somebody outside of the Cleveland Clinic, but you would want to make sure both that non-Cleveland Clinic provider and the Cleveland Clinic provider both have the most accurate medication list so they can help you avoid any drug interactions or problems.

Cassandra Holloway:  That's good advice, definitely. I love that advice for keeping a list just on your phone, maybe. How many times have we all been in a doctor's office and they've asked us what we're taking and freeze, and you're like, "Ooh, I don't know. Does my protein powder count? Do my vitamins count?" That sort of thing.

Mandy Leonard:  You might even ask the pharmacy that you go to, or your provider, they may have different types of tools or applications that they might recommend, but it can be even, like I said, as simple as just keeping a note card in your wallet, or once again, if you're comfortable using, your iPhone or something like that, you can leave it on your notes in there and you can always update it.

Cassandra Holloway:  Absolutely. Wonderful advice. So you mentioned going to different providers, or multiple providers, which I know sometimes patients can't help doing that, but I was wondering if you would talk a little bit about how to go from one pharmacy to another pharmacy or one doctor to another doctor? What should listeners know about making sure all of their care is managed, even if they're going to different pharmacists or different doctors?

Mandy Leonard:  So let me start with the pharmacies first. I completely understand, medications are expensive. We all know that. Even copays on medications can be expensive. So it may be that you might want an opportunity to call around and price out medications, and I get that. That's the main reason I think that patients use multiple pharmacies. We highly recommend that patients use one pharmacy only for the fact that we feel that the medication lists will be completely updated and the pharmacist can do all the necessary screening and counseling. But if that is something that cannot be done by a patient, then it's most important that each of the pharmacies have an accurate list of medications. So let's say you go to two pharmacies and at the one pharmacy, you get three medications filled and the other one, you only get two medications filled, it's just very important. And if there are any changes, next time you go in each of those pharmacies should be updated with your current medication list.

As far as providers, that's also really important. If your provider doesn't have access to one electronic medical record or chart, the same thing would hold true. It's very important that each of your providers know exactly what you're on because when they go to prescribe something, the physicians might realize that they shouldn't put you on one drug because it might interact with another one. And if you don't tell them that, then they wouldn't necessarily know that. Maybe the pharmacist catches that, potentially, if you go to the same pharmacy. So it's really good for your own safety and patient safety reasons just to make sure everybody is on the same page and that list is always updated.

Cassandra Holloway:  So I want to talk a little bit about staying organized. What advice do you have for people who are managing multiple medications on staying organized and getting on a schedule for taking their medications? What tips do you have?

Mandy Leonard:  So that's why you want to get a pharmacist involved, we are trained to help you do that so it'd be something that you'd want to talk to your pharmacist about. So there are certain medications that if it says, take it three times a day, well, what does that mean? Does that mean every eight hours? Or if it's take it twice a day, does that mean every 12 hours? Is it around the clock? Or there might be certain medications that have to be taken with food, so does that mean I should take it before breakfast, after breakfast? So on and so forth. So really sitting down with a pharmacist can really help map that out because there could be certain tricky things that we might have to figure out in your schedule and really to work with your lifestyle too, like how does that all work? If you have to take something before bedtime, "What if I don't go to bed at the same time every night, its that okay?" type of thing. So a pharmacist can map all of that out for you.

And then in addition, there might be, as well, applications or programs to help remind you to take the medication at a certain time. In addition, everybody's probably familiar with pillboxes that map out what should I take Monday, Tuesday, Wednesday, what time of the day, so that's another great way to keep very organized with your medications. But in summary, I would say definitely utilize the pharmacist to help you. Don't ever hesitate to want to speak with a pharmacist. I know they may look busy behind the counter, or if you have an opportunity, if you go to an outpatient visit, to have an opportunity to speak to a pharmacist, I think it's a really great opportunity. They can help you organize everything so we can make sure you take your medications properly.

A few other things to stay organized with your medications I may not have mentioned before would be definitely think about setting an alarm on your phone. I know that that helps maybe if you have to take the medication once a day and maybe it's around dinner time and you might eat dinner at different times, so that'll help keep you organized with your medications. Another thing would be is that we don't want you on any medications that you don't need to be on, and so when you go into your physician's office and you have your list of medications and that physician prescribed you the medication, I think you need to be your own patient advocate and have a frank conversation with a prescriber to see if you actually need to be on the medication. As pharmacists, we often see patients who are on medications that they don't necessarily need to be.

Now, there are many patients with chronic conditions that have to be on medications for their entire life, but there may be things that you're put on for just a short period of time, that you might only need to be on for a month or two or three and then it can be discontinued, but really be your own patient advocate and make sure you maybe write that down... A list of questions when you go into your office visit... "Would you have time to review my medication list with me and do I still need to be on any of these medications?"

Then one other thing to stay organized and manage your medications is don't forget that the pharmacist can be a great resource for the [inaudible 00:13:08] of medications. So let's say that you're having trouble affording your medications and a prescriber may have put you on one medication, you can ask the pharmacist, "Maybe is there another medication in that class of drugs that's maybe available generically?" That may be an option to help you because we want to treat you accordingly, but we also want to make sure that you can afford to take that medication.

Cassandra Holloway:  I think that's wonderful advice is using your pharmacist as a resource. I think oftentimes we don't really think that far. You know what I mean? They're [inaudible 00:13:40] behind a counter, hurrying and packing packaging pills, it could be difficult to maybe say, "Hey, can I have a couple minutes? Can I talk to you?" But I think it's a really important message that you're saying that use your pharmacist as a resource. They can help you stay organized with managing these medications.

So what advice do you have when it comes to refills? Is there anything specific our listeners should know or think about with refills?

Mandy Leonard:  So what I would say is that a lot of times refills, when you're allowed to get them, are based on your insurance coverage. So sometimes you may want to get a refill early, but you might walk into the pharmacy and the pharmacist or technician might say, "I can't fill that for you because it's too early. The insurance won't let me." So a lot of times when you should get refills is based on your insurance provider.

Now, there may be times, for example, when you're going to go on an extended vacation and you need an early refill, and that is so important to then have that discussion with your pharmacist so that they might be able to make a call or contact the insurance company, or override it, in order to make sure you have your medication when you go out of town for an extended period of time.

But what I would recommend is if you can just try to be consistent. For example, if you have a 30-day supply of medication or a 90-day supply of medication, it'd be great if you could try to get all your medications on the same timeframe. So let's say you're on five medications and your pharmacy gives you a three-month supply or 90 days, that all of those are on the same cycle versus thinking, "Okay, well, these three I have to get refilled the first of every month" or the 15th of every month. So as pharmacists, another way we try to do it is we try to help patients get on the same cycle with their refills. We've really found out that that's helped for convenience purposes and also adherence to medications.

Cassandra Holloway:  Sure. I'm assuming that the automatic refills, which are sometimes options at pharmacies, that probably helps with the getting on the same schedule as all one schedule.

Mandy Leonard:  Correct. Yeah, that's another option as well.

Cassandra Holloway:  What about expiration dates? How often do we need to be checking our labels?

Mandy Leonard:  So it's a really good question. I try to practice this at home as well. Let's talk about twofold, one, what do you have in your closet, your medicine cabinet, in your kitchen at home? My suggestion would be every six months you go through and you really look through that and see what has expired, or are there medications that maybe your physician has taken you off of them and you no longer need them. I know here at Cleveland Clinic, we have things outside of some of our retail pharmacies that allow you to... Unused medications. That's a safe way to dispose of medications. So if you're not near a Cleveland Clinic facility, you may want to see if a pharmacy near you, sometimes the police stations will have big drug take back days, that's another way to do it as well, but take anything out of your home that you don't need or is expired for that.

I know sometimes I talk to patients and you have a prescription and maybe you don't use all of it, so you... In your habit and you're like, "Well, maybe I can use this at a later date." It's really important to look at the expiration date. I'll tell you as a pharmacist, there aren't many medications that if you would use that prescription the day after it expires something terrible is going to happen, but we really need to follow those expiration dates on those labels. It can mean that if you use it past that expiration date, it could lose potency, so you may try to take something that's not going to be as efficacious as it would have been if it's taken before the expiration date. But the other thing that I worry about is some drugs over time may change properties and therefore, taking expired drugs... We don't know if you're going to experience certain side effects from that. So it's a really good idea to only take medications before their expiration date.

Cassandra Holloway:  What about storing medicine? Should we put it in a kitchen? Do we put it in the bathroom? Does it depend on the drug? What advice can you give to listeners about storing their medicine?

Mandy Leonard:  So the general rule is you want to store medications in a place where it's not very humid, and so sometimes the bathroom's not the best place for that. A lot of people might keep it in their kitchen, obviously away from the stove or something where you're doing cooking things of that nature, but it really also does depend on the medication. So it's really important when you pick up a new prescription that you want to find out the exact storage. So most medications can be kept at room temperature. However, there are medications, whether they would be something that you would self-inject, whether you would take by mouth, so let's say an antibiotic suspension or liquid or a tablet even, it might need to be stored in the refrigerator. So it's really important, before you leave the pharmacy, if you look within the pamphlet that they gave you, or you look on the label on the bottle, if you have any questions it's really important to ask, or even if you get home and you have some questions, always call the pharmacist back, they'll be able to tell you. Because you want to make sure that the drug remains efficacious and potent, and some drugs have a tendency to lose their potency if they're not stored correctly. So we want to make sure that happens, that patients store their medications correctly.

Cassandra Holloway:  So we talked a little bit today about using your pharmacist as a resource and having a relationship and getting help just managing your care and learning more about drug interactions and how and when to take your medicine. So the last thing I want to ask you about today is what advice do you have for listeners about asking questions when they're prescribed something and being an advocate in their care?

Mandy Leonard:  I think that's extremely important. We find that many patients don't know the reason why they're on a medication. And so before you leave that physician office, I would definitely make sure if you're started on a new medication, you understand why and the reason. Even if you bring a family member in and you're comfortable with them listening to that information, or you have an advocate with you... Because sometimes when we go to the doctors, it may be a very stressful time, so somebody may be telling us something but we're so stressed about it we're not actually really listening or understanding what's being said to us, so having an advocate with you that can also hear the same information is really important, as well as I know that oftentimes you might [inaudible 00:20:37] get a discharge summary or a sheet of paper that comes in aftercare visit, where you can read later for that same reason. But I think it's just really important, any new medication you understand from the prescriber the reason why you're on it.

Then another opportunity would be that when you get that prescription filled, that's another opportunity if you're asked if you want to be counseled by the pharmacist to take that opportunity to be counseled by the pharmacist. So a question that the pharmacist is going to ask you potentially is, why are you taking this medication? And then that would give you an opportunity to see if you have an understanding of why you're taking it, then the pharmacist can reinforce the reason why you're doing that and also help address any questions that you may have.

Cassandra Holloway:  I think along those lines as well is you could reach out if you're experiencing any side effects or anything negative that's happening. I think being able to reach back out and ask, "Well, why is this happening" or "What should I do" is important as well.

Mandy Leonard:  Yeah. We say, as pharmacists too, that we are easily accessible healthcare professionals. So think about it, you have all the pharmacies out there in the community that are open, they're a phone call away, and so oftentimes where you get your prescription filled, that pharmacist you have readily... You have access to that pharmacist just by a phone call where it may take maybe a little longer to reach your doctor. So the point being is you may want to try a pharmacist to see if they can resolve any questions or issues that you may have, and that might be helpful to you.

Cassandra Holloway:  Awesome. That's great advice and I think a really great ending point. You've provided so many great insights and knowledge today, so thank you, Mandy, for taking the time to speak with us.

Mandy Leonard:  Absolutely. I appreciate the time and I hope everybody stays safe out there during this time.

Cassandra Holloway:  To learn more about pharmacy services at Cleveland Clinic, visit clevelandclinic.org/pharmacy. If you want to listen to more Health Essentials podcasts, featuring experts at Cleveland Clinic, subscribe wherever you get your podcasts from or visit clevelandclinic.org/hepodcasts. Also, don't forget to follow us on Facebook, Twitter, and Instagram, @Clevelandclinic, all one word, to stay up to date on the latest news and information. Thanks again for listening and stay well.