MTM Polypharmacy Assessment & Reduction 3 — Questions and Answers
Question 1: A patient takes warfarin and is started on fluconazole for a fungal infection. During an MTM follow-up, the INR rises from 2.4 to 4.8. This is BEST classified as which type of drug-drug interaction?
- Pharmacokinetic interaction via CYP2C9 inhibition (Correct answer)
- Pharmacodynamic synergism
- Protein binding displacement
- Induction of clotting factor synthesis
Correct answer: Pharmacokinetic interaction via CYP2C9 inhibition
Fluconazole inhibits CYP2C9, the primary enzyme responsible for warfarin (S-enantiomer) metabolism, leading to elevated warfarin levels and increased anticoagulation.
Question 2: When using the Medication Appropriateness Index (MAI) during polypharmacy assessment, how many criteria does the tool evaluate for each medication?
- 10 (Correct answer)
- 5
- 7
- 15
Correct answer: 10
The MAI evaluates 10 criteria for each medication including indication, effectiveness, dosage, directions, drug interactions, and cost.
Question 3: A 72-year-old patient with hypertension, heart failure, and CKD stage 3 is taking lisinopril 40 mg, spironolactone 25 mg, and potassium chloride supplements. Which concern should the pharmacist prioritize?
- Hyperkalemia risk from concurrent use of multiple potassium-retaining agents (Correct answer)
- Hypotension from excessive antihypertensive therapy
- Inadequate diuresis in heart failure management
- Renal toxicity from ACE inhibitor use
Correct answer: Hyperkalemia risk from concurrent use of multiple potassium-retaining agents
Concurrent use of an ACE inhibitor, aldosterone antagonist, and potassium supplement significantly increases the risk of life-threatening hyperkalemia.
Question 4: Which principle guides the deprescribing process in polypharmacy management?
- Tapering or discontinuing one medication at a time to monitor for withdrawal or disease recurrence (Correct answer)
- Stopping all inappropriate medications simultaneously for efficiency
- Replacing multiple medications with a single combination product
- Deferring deprescribing decisions to the prescribing physician only
Correct answer: Tapering or discontinuing one medication at a time to monitor for withdrawal or disease recurrence
Discontinuing one medication at a time allows for monitoring of withdrawal effects and disease recurrence attributable to each specific medication.
Question 5: A pharmacist conducting an MTM session identifies that a patient takes aspirin 81 mg for primary prevention. Per current evidence, what is the MOST appropriate recommendation for a 76-year-old patient with no prior cardiovascular events?
- Recommend deprescribing aspirin as benefits no longer outweigh bleeding risks in primary prevention for this age group (Correct answer)
- Continue aspirin indefinitely for all patients over 65
- Increase aspirin to 325 mg for better efficacy
- Add a PPI to mitigate GI bleeding risk and continue aspirin
Correct answer: Recommend deprescribing aspirin as benefits no longer outweigh bleeding risks in primary prevention for this age group
Current guidelines recommend against initiating or continuing aspirin for primary prevention in adults over 60 due to increased bleeding risk outweighing cardiovascular benefits.
Question 6: Which patient-centered technique is MOST effective when discussing medication reduction with a patient who is resistant to deprescribing?
- Motivational interviewing to explore the patient's concerns and goals (Correct answer)
- Prescribing additional medications to offset the risks of current regimen
- Providing a detailed list of adverse effects for each medication
- Involving family members to pressure the patient into compliance
Correct answer: Motivational interviewing to explore the patient's concerns and goals
Motivational interviewing helps elicit the patient's own motivation for change by exploring ambivalence and aligning medication decisions with personal health goals.
Question 7: During reconciliation, a pharmacist discovers a patient takes both sertraline and tramadol. Which serious drug interaction is of GREATEST concern?
- Serotonin syndrome (Correct answer)
- QT prolongation
- Respiratory depression
- Hepatotoxicity
Correct answer: Serotonin syndrome
Concurrent use of sertraline (SSRI) and tramadol (serotonin reuptake inhibitor and weak opioid) significantly increases the risk of serotonin syndrome.
MTM Polypharmacy Assessment & Reduction 3
A patient takes warfarin and is started on fluconazole for a fungal infection.
During an MTM follow-up, the INR rises from 2.4 to 4.8.
This is BEST classified as which type of drug-drug interaction?