MTM Comprehensive Medication Review & Optimization 2 — Questions and Answers
Question 1: During a CMR, a patient taking warfarin reports recently starting fish oil supplements. What is the primary concern?
- Reduced warfarin absorption
- Additive anticoagulant effect increasing bleeding risk (Correct answer)
- Fish oil inactivates warfarin enzymes
- No significant interaction exists
Correct answer: Additive anticoagulant effect increasing bleeding risk
Fish oil has antiplatelet properties that can potentiate warfarin's anticoagulant effect, increasing bleeding risk.
Question 2: A CMR reveals a patient is taking both a PPI and clopidogrel. What is the most clinically significant concern?
- PPIs increase clopidogrel toxicity
- PPIs reduce clopidogrel's antiplatelet activation via CYP2C19 inhibition (Correct answer)
- Clopidogrel blocks PPI absorption
- PPIs cause clopidogrel resistance through pharmacodynamic antagonism
Correct answer: PPIs reduce clopidogrel's antiplatelet activation via CYP2C19 inhibition
PPIs (especially omeprazole) inhibit CYP2C19, reducing conversion of clopidogrel to its active metabolite and diminishing antiplatelet effect.
Question 3: Which STOPP criteria medication combination should prompt immediate reconciliation review in an elderly CMR patient?
- ACE inhibitor + ARB
- Beta-blocker + calcium channel blocker
- NSAID + anticoagulant (Correct answer)
- Statin + fibrate
Correct answer: NSAID + anticoagulant
STOPP criteria flag NSAID + anticoagulant combinations due to significantly elevated GI bleeding risk in elderly patients.
Question 4: A patient's MAP (Medication Action Plan) following a CMR should primarily be written for whom?
- The prescribing physician only
- The dispensing pharmacist
- The patient in plain language they can understand (Correct answer)
- The insurance company for prior authorization
Correct answer: The patient in plain language they can understand
The MAP is a patient-facing document written in plain language to help patients understand and act on medication-related recommendations.
Question 5: During CMR documentation, a pharmacist identifies a drug without a documented indication. According to NCC MERP taxonomy, this best represents:
- An adverse drug reaction
- A drug therapy problem — unnecessary drug therapy (Correct answer)
- A medication error at dispensing
- A contraindication requiring emergent action
Correct answer: A drug therapy problem — unnecessary drug therapy
A drug lacking a documented indication classifies as unnecessary drug therapy under the Cipolle/Strand drug therapy problem framework.
Question 6: A 72-year-old patient on metformin has a new lab showing eGFR of 28 mL/min/1.73m². The appropriate CMR recommendation is:
- Continue metformin; GFR threshold is not clinically relevant
- Reduce metformin dose by 50%
- Discontinue metformin due to lactic acidosis risk below eGFR 30 (Correct answer)
- Switch to insulin immediately without further assessment
Correct answer: Discontinue metformin due to lactic acidosis risk below eGFR 30
Metformin is contraindicated when eGFR falls below 30 mL/min/1.73m² due to accumulation risk and potential for lactic acidosis.
Question 7: Which element is REQUIRED in a completed CMR encounter documentation per CMS guidelines?
- Patient's insurance premium information
- A list of all prescribers with their NPI numbers
- A medication list with indication, dose, route, and frequency (Correct answer)
- Pharmacy dispensing records for the past 5 years
Correct answer: A medication list with indication, dose, route, and frequency
CMS requires the CMR documentation to include a comprehensive medication list with indication, dose, route, and frequency for each medication.
MTM Comprehensive Medication Review & Optimization 2
During a CMR, a patient taking warfarin reports recently starting fish oil supplements.
What is the primary concern?