CCP Medication Therapy Management 3 — Questions and Answers
Question 1: A consultant pharmacist reviews a nursing home resident's medication list and notes that metoclopramide has been prescribed continuously for 18 months. Which concern should be raised with the medical team?
- Risk of QT prolongation requiring ECG monitoring
- Risk of tardive dyskinesia with long-term use beyond 12 weeks (Correct answer)
- Risk of nephrotoxicity requiring serum creatinine monitoring
- Risk of Stevens-Johnson syndrome requiring skin assessment
Correct answer: Risk of tardive dyskinesia with long-term use beyond 12 weeks
FDA requires a black-box warning on metoclopramide for tardive dyskinesia risk with use beyond 12 weeks, making long-term prescribing a significant concern.
Question 2: During a CMR, a patient with type 2 diabetes reports that she skips her evening metformin dose 'because it upsets her stomach.' The pharmacist's BEST recommendation to improve adherence while minimizing GI side effects is:
- Switch to insulin glargine
- Switch to metformin extended-release taken with the evening meal (Correct answer)
- Add a proton pump inhibitor to the regimen
- Reduce the metformin dose by half and add a sulfonylurea
Correct answer: Switch to metformin extended-release taken with the evening meal
Extended-release metformin has significantly lower GI side effects than immediate-release and, when taken with food, further reduces GI intolerance.
Question 3: In the context of MTM documentation, a 'Personal Medication Record' (PMR) differs from a 'Medication Action Plan' (MAP) in that:
- The PMR lists all current medications and is for the patient's reference; the MAP lists specific actions the patient needs to take (Correct answer)
- The PMR is a prescriber document; the MAP is shared only with the payer
- The PMR covers only controlled substances; the MAP covers all drug classes
- The PMR is completed annually; the MAP is completed at each dispensing event
Correct answer: The PMR lists all current medications and is for the patient's reference; the MAP lists specific actions the patient needs to take
The PMR is a comprehensive patient-held medication list, while the MAP is a patient-centered action document specifying steps the patient must take to optimize therapy.
Question 4: A pharmacist is evaluating a 70-year-old patient's medications using the Beers Criteria. Which combination of findings would be MOST consistent with Beers Criteria concerns in this population?
- Lisinopril + amlodipine + atorvastatin
- Diphenhydramine for sleep + oxybutynin for urge incontinence + diazepam for anxiety (Correct answer)
- Metformin + empagliflozin + sitagliptin
- Losartan + hydrochlorothiazide + metoprolol succinate
Correct answer: Diphenhydramine for sleep + oxybutynin for urge incontinence + diazepam for anxiety
Diphenhydramine, oxybutynin, and diazepam are all strongly anticholinergic or CNS-depressant agents listed as potentially inappropriate in older adults per Beers Criteria.
Question 5: An MTM pharmacist is performing a medication reconciliation for a patient transitioning from hospital to home. The patient's discharge medication list includes warfarin 5mg daily, but the pharmacist's pre-admission record shows the patient was on warfarin 2.5mg daily. The most appropriate next step is:
- Dispense the 5mg dose since it is the most recent order
- Contact the discharging physician to determine if the dose change was intentional (Correct answer)
- Instruct the patient to alternate 2.5mg and 5mg doses
- Schedule a CMR in 90 days to reassess
Correct answer: Contact the discharging physician to determine if the dose change was intentional
A dosage discrepancy between pre-admission and discharge records for a high-alert medication like warfarin requires immediate prescriber clarification to prevent harm.
Question 6: A CCP reviewing a patient's anticoagulation therapy notes the patient is on apixaban for atrial fibrillation but also takes clarithromycin for a respiratory infection. The pharmacist should be MOST concerned about:
- Reduced apixaban efficacy due to P-gp induction
- Increased apixaban exposure due to combined P-gp and CYP3A4 inhibition (Correct answer)
- Increased risk of thrombosis due to clarithromycin's procoagulant effects
- Reduced clarithromycin efficacy due to apixaban induction of CYP3A4
Correct answer: Increased apixaban exposure due to combined P-gp and CYP3A4 inhibition
Clarithromycin inhibits both P-glycoprotein and CYP3A4, the primary elimination pathways for apixaban, leading to significantly increased apixaban exposure and bleeding risk.
Question 7: Which of the following outcomes is MOST directly aligned with the goals of an MTM program as defined by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA)?
- Increasing the number of medications patients take
- Optimizing therapeutic outcomes and reducing adverse drug events (Correct answer)
- Ensuring all medications are dispensed as written without substitution
- Maximizing generic drug utilization to reduce plan costs
Correct answer: Optimizing therapeutic outcomes and reducing adverse drug events
The MMA established MTM programs to optimize therapeutic outcomes for targeted beneficiaries and reduce the risk of adverse drug events.
CCP Medication Therapy Management 3
A consultant pharmacist reviews a nursing home resident's medication list and notes that metoclopramide has been prescribed continuously for 18 months.
Which concern should be raised with the medical team?