Providing pharmaceutical care in a physician office.

OBJECTIVE: To develop a physician office-based pharmaceutical care practice and evaluate the impact on the participating physicians, their staff, and patients. SETTING: Internal medicine physician office. PRACTICE DESCRIPTION: Two physicians and two nurses practice in a medical office complex in a rural setting in eastern Washington. PRACTICE INNOVATION: Development of an experimental pharmaceutical care program in which a registered pharmacist works in a physician office to evaluate the medication needs of patients and to provide pharmaceutical care and medication information to health professionals and patients. MAIN OUTCOME MEASURES: Functions and interventions performed by the pharmacist; types of disease states in patients that were confronted by the pharmacist; summary of time spent with patients; and attitudes of physicians and patients concerning the pharmacist interventions. RESULTS: 660 pharmacist interventions or functions occurred during the seven months of the project. Of 107 recommendations to the physicians concerning changes in therapy, 89 were accepted. Patients suffered from 53 different disease states that were evaluated by the pharmacist. The pharmacist spent from less than 5 minutes to more than an hour with individual patients, 5 to 15 minutes with the majority of patients. Both patients and physicians were impressed with the service and strongly desired to have it continued. CONCLUSION: There is a career opportunity for pharmacists to provide pharmaceutical care in the setting of a physician office practice. Many of the barriers to providing pharmaceutical care can be eliminated or diminished in this setting.

Metformin: a new oral biguanide.

The biguanide metformin is an oral anti-hyperglycemic agent used in the treatment of patients with non-insulin-dependent diabetes mellitus (NIDDM). Metformin is an important addition to the drug therapy options available for those patients because it reduces blood glucose levels predominantly by decreasing hepatic glucose production and release and also by increasing peripheral tissue sensitivity to insulin; it does not stimulate insulin secretion from the beta cells in the pancreas. Metformin also has a potentially beneficial effect by reducing serum lipid levels. Its glycemic control is similar to that of the sulfonylureas and is effective as monotherapy or in combination with sulfonylureas or insulin. Unlike sulfonylureas and insulin, it does not cause a gain in body weight, and when used as monotherapy, it does not cause hypoglycemia. The most common side effects associated with metformin are mild, transient, gastrointestinal symptoms, which are usually self-limiting. These side effects can be minimized by initiating metformin therapy at a low dose and gradually titrating upward, and by taking metformin with meals. Lactic acidosis caused by metformin is rare, and the risk of this complication may be diminished by the observance of prescribing precautions and contraindications that avoid accumulation of metformin or lactate in the body. In patients who are not getting the desired effect with sulfonylureas, it is useful to combine sulfonylureas with metformin therapy. Metformin should be considered a first-line agent, particularly in obese and/or hyperlipidemic NIDDM patients.