MTM Specialty Medication Management 2 — Questions and Answers
Question 1: A patient on adalimumab for rheumatoid arthritis develops a positive QuantiFERON-TB Gold test before therapy initiation. What is the appropriate MTM intervention?
- Discontinue adalimumab permanently
- Initiate latent TB treatment with isoniazid for 9 months before starting adalimumab (Correct answer)
- Proceed with adalimumab and monitor chest X-ray monthly
- Switch to a non-biologic DMARD without TB testing
Correct answer: Initiate latent TB treatment with isoniazid for 9 months before starting adalimumab
Latent TB must be treated (typically 9 months of isoniazid) before initiating TNF inhibitors like adalimumab to prevent reactivation.
Question 2: Which monitoring parameter is MOST critical when initiating sacubitril/valsartan (Entresto) in a heart failure patient already on an ACE inhibitor?
- Blood glucose
- Serum potassium and renal function after a 36-hour washout period (Correct answer)
- Liver function tests
- Complete blood count
Correct answer: Serum potassium and renal function after a 36-hour washout period
A 36-hour washout of ACE inhibitors is required before starting sacubitril/valsartan to prevent life-threatening angioedema due to bradykinin accumulation.
Question 3: A patient taking lenalidomide for multiple myeloma asks about pregnancy prevention. What is required per the REMS program?
- Monthly urine pregnancy tests only
- Two forms of contraception plus monthly pregnancy testing and counseling enrollment in RevAssist (Correct answer)
- One form of contraception and quarterly pregnancy tests
- Abstinence alone is acceptable if documented
Correct answer: Two forms of contraception plus monthly pregnancy testing and counseling enrollment in RevAssist
RevAssist REMS requires two forms of contraception and monthly pregnancy testing for females of reproductive potential due to severe teratogenicity.
Question 4: When counseling a patient on oral anticoagulation with rivaroxaban who also takes omeprazole, which interaction concern is MOST clinically relevant?
- Omeprazole increases rivaroxaban bleeding risk
- Omeprazole reduces rivaroxaban absorption when taken without food
- Rivaroxaban 20 mg must be taken with the evening meal; omeprazole has no significant interaction (Correct answer)
- Omeprazole displaces rivaroxaban from protein binding sites
Correct answer: Rivaroxaban 20 mg must be taken with the evening meal; omeprazole has no significant interaction
Rivaroxaban 20 mg must be taken with the evening meal to maximize bioavailability; omeprazole does not significantly alter rivaroxaban pharmacokinetics.
Question 5: A pharmacist performing MTM for a patient on clozapine identifies an ANC of 800 cells/µL. What action is required?
- Continue clozapine and recheck ANC in 6 months
- Immediately discontinue clozapine and notify the prescriber (Correct answer)
- Reduce clozapine dose by 50% and recheck ANC weekly
- Hold clozapine for 48 hours and restart at a lower dose
Correct answer: Immediately discontinue clozapine and notify the prescriber
An ANC below 1000 cells/µL mandates immediate discontinuation of clozapine per REMS requirements due to risk of severe neutropenia/agranulocytosis.
Question 6: Which specialty medication requires refrigeration during storage but can be kept at room temperature for a limited period after removal from the refrigerator?
- Oral imatinib (Gleevec)
- Adalimumab (Humira) prefilled syringe (Correct answer)
- Apixaban (Eliquis)
- Methotrexate oral tablets
Correct answer: Adalimumab (Humira) prefilled syringe
Adalimumab may be stored at room temperature (up to 77°F/25°C) for up to 14 days once removed from refrigeration, after which it must be discarded.
Question 7: A patient on sunitinib for renal cell carcinoma reports new-onset jaw pain with tooth loosening. Which specialty medication-related complication should be investigated?
- Drug-induced lupus
- Medication-related osteonecrosis of the jaw (MRONJ) (Correct answer)
- Sunitinib-induced peripheral neuropathy
- Bisphosphonate toxicity
Correct answer: Medication-related osteonecrosis of the jaw (MRONJ)
MRONJ can occur with anti-angiogenic agents like sunitinib, particularly following dental procedures, and requires prompt dental evaluation.
MTM Specialty Medication Management 2
A patient on adalimumab for rheumatoid arthritis develops a positive QuantiFERON-TB Gold test before therapy initiation.
What is the appropriate MTM intervention?