MTM Chronic Disease Management 5 — Questions and Answers
Question 1: Which medication used in chronic disease management is most likely to cause hyperkalemia when added to an ACE inhibitor in a patient with CKD stage 3?
- Spironolactone (Correct answer)
- Amlodipine
- Atorvastatin
- Metformin
Correct answer: Spironolactone
Spironolactone (a potassium-sparing diuretic/mineralocorticoid antagonist) combined with an ACE inhibitor in CKD significantly increases the risk of life-threatening hyperkalemia.
Question 2: A patient with type 2 diabetes, CKD stage 3b, and cardiovascular disease is being considered for an SGLT-2 inhibitor primarily for cardiorenal protection. Which agent has an FDA indication for this use down to eGFR 20 mL/min/1.73m²?
- Dapagliflozin (Farxiga) (Correct answer)
- Canagliflozin (Invokana)
- Empagliflozin (Jardiance) for HFrEF indication
- Ertugliflozin (Steglatro)
Correct answer: Dapagliflozin (Farxiga)
Dapagliflozin received FDA approval for CKD progression reduction down to eGFR ≥25 mL/min/1.73m² (and HF indication), with canagliflozin having CKD data as well — but dapagliflozin's label extends to eGFR 25.
Question 3: A patient on warfarin for atrial fibrillation begins taking amiodarone for rate/rhythm control. The pharmacist should anticipate:
- Significantly increased INR requiring warfarin dose reduction of 30–50% (Correct answer)
- Decreased INR due to enzyme induction by amiodarone
- No clinically significant interaction between the two drugs
- Increased warfarin requirements due to faster elimination
Correct answer: Significantly increased INR requiring warfarin dose reduction of 30–50%
Amiodarone is a potent inhibitor of CYP2C9 (and other CYPs), markedly reducing warfarin metabolism and increasing anticoagulant effect, often necessitating a 30–50% empiric dose reduction.
Question 4: Which non-pharmacologic intervention has the highest level of evidence for reducing cardiovascular mortality in patients with stable coronary artery disease?
- Cardiac rehabilitation program participation (Correct answer)
- Routine daily vitamin E supplementation
- Acupuncture for chest pain management
- Chelation therapy for plaque removal
Correct answer: Cardiac rehabilitation program participation
Cardiac rehabilitation is supported by strong evidence showing reductions in cardiovascular mortality, hospitalizations, and improved quality of life in patients with established CAD.
Question 5: A patient with well-controlled asthma asks whether she still needs her daily inhaled corticosteroid now that she has been symptom-free for 6 months. The pharmacist's BEST response is:
- Inhaled corticosteroids should be continued as they address underlying airway inflammation, and stopping abruptly often leads to relapse (Correct answer)
- She can stop the ICS safely since she has been symptom-free for 6 months
- Replace the ICS with an as-needed LABA for maintenance
- Switch to an oral leukotriene antagonist since she is well controlled
Correct answer: Inhaled corticosteroids should be continued as they address underlying airway inflammation, and stopping abruptly often leads to relapse
ICS remains the cornerstone of persistent asthma management because symptom control does not equal resolution of underlying inflammation; abrupt discontinuation frequently leads to return of symptoms.
Question 6: In the context of MTM for a patient with multiple chronic conditions, what is the primary goal of creating a Personal Medication Record (PMR)?
- To provide the patient with a comprehensive, up-to-date list of all medications, doses, and indications for self-management and emergency use (Correct answer)
- To serve as a billing document for reimbursement of MTM services
- To replace the need for a medication therapy problem (MTP) documentation
- To track only prescription medications dispensed at one pharmacy
Correct answer: To provide the patient with a comprehensive, up-to-date list of all medications, doses, and indications for self-management and emergency use
The PMR is a patient-facing document that lists all medications (prescription, OTC, supplements) with doses and indications, empowering patients and ensuring accurate information is available during transitions of care.
Question 7: A patient with type 2 diabetes, hypertension, and microalbuminuria should have nephroprotective therapy initiated with which drug class as the first-line antihypertensive?
- ACE inhibitor or ARB (Correct answer)
- Thiazide diuretic
- Dihydropyridine calcium channel blocker
- Beta-blocker
Correct answer: ACE inhibitor or ARB
ACE inhibitors and ARBs reduce intraglomerular pressure and have proven nephroprotective effects in diabetic kidney disease, making them the preferred antihypertensive class when proteinuria is present.
MTM Chronic Disease Management 5
Which medication used in chronic disease management is most likely to cause hyperkalemia when added to an ACE inhibitor in a patient with CKD stage 3?