MTM Chronic Disease Management 4 — Questions and Answers
Question 1: A patient with type 2 diabetes and an eGFR of 38 mL/min/1.73m² needs additional glucose lowering. Which agent is contraindicated or not recommended at this eGFR?
- SGLT-2 inhibitors (most agents lose glycemic efficacy below eGFR 45) (Correct answer)
- GLP-1 receptor agonists (liraglutide or semaglutide)
- Insulin (basal or bolus regimens)
- DPP-4 inhibitors with appropriate dose adjustment
Correct answer: SGLT-2 inhibitors (most agents lose glycemic efficacy below eGFR 45)
Most SGLT-2 inhibitors are not recommended for glycemic control when eGFR falls below 45 mL/min/1.73m² due to loss of efficacy, though some may be continued for cardio/renal benefits per updated labeling.
Question 2: Which intervention has the strongest evidence for reducing hospitalizations in patients with heart failure with reduced ejection fraction?
- Optimizing guideline-directed medical therapy (ACEi/ARB/ARNI + beta-blocker + MRA + SGLT-2i) (Correct answer)
- Restricting dietary sodium to less than 1500 mg/day alone
- Daily supervised aerobic exercise program alone
- Adding digoxin as the primary intensification strategy
Correct answer: Optimizing guideline-directed medical therapy (ACEi/ARB/ARNI + beta-blocker + MRA + SGLT-2i)
The four-pillar GDMT (RAAS inhibitor, beta-blocker, mineralocorticoid antagonist, and SGLT-2 inhibitor) has robust evidence for reducing hospitalizations and mortality in HFrEF.
Question 3: In a patient with hypertension and bilateral renal artery stenosis, which antihypertensive class is CONTRAINDICATED?
- ACE inhibitors and ARBs (Correct answer)
- Thiazide diuretics
- Dihydropyridine calcium channel blockers
- Alpha-1 blockers
Correct answer: ACE inhibitors and ARBs
ACE inhibitors and ARBs block angiotensin II–mediated efferent arteriole constriction, which can cause acute renal failure in bilateral renal artery stenosis.
Question 4: A patient with persistent asthma uses an inhaled corticosteroid but remains uncontrolled. Per NAEPP Step 3 therapy, the preferred add-on is:
- A long-acting beta-agonist (LABA) combined with the ICS (Correct answer)
- Adding a leukotriene receptor antagonist and discontinuing ICS
- Switching to an oral corticosteroid as primary maintenance
- Adding a short-acting muscarinic antagonist (ipratropium)
Correct answer: A long-acting beta-agonist (LABA) combined with the ICS
NAEPP Step 3 preferred therapy is a low-dose ICS/LABA combination, which improves bronchodilation and anti-inflammatory control better than ICS dose escalation alone.
Question 5: Which vaccine is recommended annually for all patients with chronic obstructive pulmonary disease regardless of age?
- Influenza vaccine (Correct answer)
- Meningococcal vaccine
- Herpes zoster vaccine
- Japanese encephalitis vaccine
Correct answer: Influenza vaccine
Annual influenza vaccination is recommended for all COPD patients because influenza is a major trigger of COPD exacerbations and is associated with significant morbidity in this population.
Question 6: A patient with gout has a serum uric acid of 9.2 mg/dL and two attacks in the past year. Which urate-lowering therapy target is recommended?
- Serum uric acid below 6.0 mg/dL (Correct answer)
- Serum uric acid below 7.0 mg/dL
- Serum uric acid below 8.0 mg/dL
- Serum uric acid below 5.0 mg/dL
Correct answer: Serum uric acid below 6.0 mg/dL
ACR guidelines recommend a serum uric acid target of <6.0 mg/dL (and <5.0 mg/dL in severe gout) to dissolve existing tophi and prevent recurrent attacks.
Question 7: During an MTM consultation, a patient with type 2 diabetes reveals she stopped taking her insulin because she is afraid of needles. The pharmacist's BEST initial response is to:
- Explore the patient's specific concerns and discuss alternative delivery options or pen devices (Correct answer)
- Document non-compliance and notify the prescriber without further discussion
- Reassure her that injections are painless and she should resume immediately
- Switch her to an oral agent without consulting the prescriber
Correct answer: Explore the patient's specific concerns and discuss alternative delivery options or pen devices
Motivational interviewing techniques that explore and validate the patient's fears, combined with education on modern delivery devices, are most effective for addressing insulin reluctance.
MTM Chronic Disease Management 4
A patient with type 2 diabetes and an eGFR of 38 mL/min/1.73m² needs additional glucose lowering.
Which agent is contraindicated or not recommended at this eGFR?