MTM Specialty Medication Management 3 — Questions and Answers
Question 1: A patient with relapsing-remitting multiple sclerosis is starting natalizumab. Which laboratory test is MOST important to obtain prior to initiation?
- Hepatitis B surface antigen
- JC virus antibody (JCV index) (Correct answer)
- Tuberculin skin test
- Varicella zoster IgG titer
Correct answer: JC virus antibody (JCV index)
JCV antibody status must be assessed before natalizumab initiation because JCV-positive patients have significantly higher risk of progressive multifocal leukoencephalopathy (PML).
Question 2: During an MTM session, a patient on trastuzumab (Herceptin) for HER2-positive breast cancer asks about heart-related risks. What monitoring is standard?
- Annual stress test
- Echocardiogram or MUGA scan at baseline and every 3 months during therapy (Correct answer)
- Monthly ECG
- Serum troponin monthly
Correct answer: Echocardiogram or MUGA scan at baseline and every 3 months during therapy
Cardiac function (LVEF) must be assessed at baseline and every 3 months during trastuzumab therapy due to risk of cardiotoxicity.
Question 3: A patient on abiraterone acetate (Zytiga) for prostate cancer has a new prescription for prednisone. Why is concurrent corticosteroid use required?
- To prevent hypersensitivity reactions to abiraterone
- To counteract mineralocorticoid excess caused by CYP17 inhibition (Correct answer)
- To enhance abiraterone bioavailability
- To prevent hepatotoxicity
Correct answer: To counteract mineralocorticoid excess caused by CYP17 inhibition
Abiraterone inhibits CYP17, causing mineralocorticoid accumulation leading to hypertension, hypokalemia, and fluid retention; low-dose corticosteroids counteract this effect.
Question 4: Which of the following is a BLACK BOX WARNING associated with fingolimod (Gilenya) for multiple sclerosis?
- Pulmonary embolism
- Bradycardia and AV block at initiation requiring first-dose observation (Correct answer)
- Agranulocytosis
- Hepatic necrosis
Correct answer: Bradycardia and AV block at initiation requiring first-dose observation
Fingolimod can cause bradycardia and AV block upon first dose, requiring 6-hour observation with cardiac monitoring in a healthcare setting.
Question 5: A patient on warfarin starts apremilast (Otezla) for psoriasis. What drug interaction concern should the pharmacist address?
- Apremilast is a potent CYP2C9 inhibitor that markedly increases warfarin levels
- Apremilast has no significant interaction with warfarin (Correct answer)
- Apremilast induces CYP3A4 and may reduce warfarin effect
- Apremilast increases vitamin K absorption
Correct answer: Apremilast has no significant interaction with warfarin
Apremilast does not have significant pharmacokinetic interactions with warfarin and can be used without dose adjustment.
Question 6: A patient newly prescribed ibrutinib for CLL asks about dietary restrictions. What is the MOST important counseling point?
- Avoid dairy products
- Avoid grapefruit and grapefruit juice due to CYP3A4 inhibition (Correct answer)
- Take with a high-fat meal to improve absorption
- Avoid all vitamin supplements
Correct answer: Avoid grapefruit and grapefruit juice due to CYP3A4 inhibition
Grapefruit inhibits CYP3A4, the primary enzyme metabolizing ibrutinib, which can increase ibrutinib plasma concentrations and toxicity.
Question 7: Which monitoring parameter should be prioritized during MTM for a patient on dupilumab (Dupixent) for atopic dermatitis?
- Serum IgE levels monthly
- Ophthalmologic evaluation for conjunctivitis (Correct answer)
- Liver function tests quarterly
- CBC with differential monthly
Correct answer: Ophthalmologic evaluation for conjunctivitis
Conjunctivitis is the most common adverse effect of dupilumab, occurring in up to 10% of patients, requiring ophthalmologic monitoring.
MTM Specialty Medication Management 3
A patient with relapsing-remitting multiple sclerosis is starting natalizumab.
Which laboratory test is MOST important to obtain prior to initiation?