MTM Cheat Sheet 2026

The 30 highest-yield MTM facts, distilled from real exam questions. Print it, save it as a PDF, or study it here — free, no sign-up.

1. A patient on warfarin is transitioning from hospital to home. The safest protocol includes all of the following EXCEPT: → Automatically resuming the pre-hospitalization warfarin dose without assessment
2. During a CMR, a patient taking warfarin reports recently starting fish oil supplements. What is the primary concern? → Additive anticoagulant effect increasing bleeding risk
3. A patient with schizophrenia on clozapine develops an absolute neutrophil count (ANC) of 900 cells/mm³. What is the most appropriate action? → Discontinue clozapine immediately
4. A pharmacist performing MTM for a patient on clozapine identifies an ANC of 800 cells/µL. What action is required? → Immediately discontinue clozapine and notify the prescriber
5. A patient with acute PE is found to have antiphospholipid syndrome (APS). Which anticoagulant strategy is preferred for long-term management? → Warfarin with target INR 2–3
6. Which monitoring parameter is MOST critical when initiating sacubitril/valsartan (Entresto) in a heart failure patient already on an ACE inhibitor? → Serum potassium and renal function after a 36-hour washout period
7. Which of the following medications used in heart failure has been shown to improve glycemic control in patients with T2DM by reducing insulin resistance? → Carvedilol
8. Which of the following best describes the primary mechanism by which GLP-1 receptor agonists reduce cardiovascular events? → Direct anti-atherosclerotic and anti-inflammatory effects on vessel walls
9. A CMR patient reports forgetting her afternoon medication dose consistently. Which adherence strategy is most evidence-based for this pattern? → Switching to a twice-daily formulation if a once-daily equivalent is available
10. A patient with mechanical mitral valve replacement asks about switching from warfarin to a DOAC. What is the appropriate recommendation? → DOACs are contraindicated in patients with mechanical heart valves
11. When setting medication-related goals with a patient, the MTM pharmacist should ensure goals are SMART. What does the 'A' in SMART stand for? → Achievable
12. A patient with moderate hepatic impairment requires opioid therapy. Which opioid should be used with the MOST caution due to active metabolite accumulation? → Morphine
13. Which element is essential in regulatory documentation? → All clinical data and legally required elements
14. During an MTM session, a patient on dabigatran reports taking an over-the-counter proton pump inhibitor. What counseling point is most relevant? → PPIs reduce dabigatran bioavailability by increasing gastric pH
15. A patient on warfarin for atrial fibrillation is starting fluconazole for a vaginal yeast infection. What action should be taken? → Decrease the warfarin dose by approximately 25–50% and monitor INR closely
16. A patient with T2DM and stage 4 CKD (eGFR 22 mL/min) needs improved glycemic control. Which agent is safest to initiate? → Insulin glargine
17. An MTM pharmacist counsels a pregnant patient with depression. Which antidepressant is generally considered safest in the first trimester? → Sertraline
18. Which of the following best describes a key competency required for renal dosing & adjustments in MTM practice? → Strong analytical skills combined with effective communication and ethical judgment
19. A pharmacist identifies a patient who is a 'low health activator' on the Patient Activation Measure (PAM). Which approach is MOST appropriate? → Set small, confidence-building goals and provide strong support
20. Which tool is most appropriate for an MTM pharmacist to use when screening a patient for opioid misuse risk before initiating long-term opioid therapy? → ORT (Opioid Risk Tool)
21. Which statement about metformin and renal function is CORRECT per current guidelines? → Metformin can be continued with dose reduction when eGFR is 30–45 mL/min/1.73m²
22. A patient on peritoneal dialysis requires antibiotic therapy for peritonitis. Which route of administration is preferred? → Intraperitoneal
23. What is the primary mechanism of action of protamine sulfate when used to reverse heparin? → Directly binds heparin via electrostatic interaction, forming an inactive complex
24. What is the significance of the half-life of a drug? → It determines how often the drug is taken
25. A patient on vedolizumab (Entyvio) for Crohn's disease asks if they can receive live vaccines. What is the appropriate counseling? → Live vaccines are contraindicated; inactivated vaccines are preferred
26. Why are peak and trough levels monitored for certain antibiotics? → To optimize dosing and reduce toxicity
27. Which clinical parameter is the BEST surrogate marker for monitoring response to statin therapy in a high-risk cardiovascular patient? → Percent reduction in LDL-C from baseline
28. Which proton pump inhibitor requires the LEAST concern for dose adjustment in severe renal impairment? → All PPIs require equal adjustment in renal failure
29. Which definition BEST describes 'hyperpolypharmacy' as used in geriatric pharmacotherapy literature? → Concurrent use of 10 or more medications
30. Which clinical indicator best confirms therapeutic response to bisphosphonate therapy in a patient with osteoporosis after 2 years of treatment? → DEXA scan shows T-score improvement from -2.8 to -2.3