MTM Specialty Medication Management 5 — Questions and Answers
Question 1: A pharmacist reviews a patient on tacrolimus post-kidney transplant who has started erythromycin. What action is MOST appropriate?
- No intervention needed; the combination is safe
- Contact the prescriber: erythromycin inhibits CYP3A4 and P-gp, likely causing tacrolimus toxicity (Correct answer)
- Advise the patient to take tacrolimus and erythromycin 4 hours apart
- Recommend stopping tacrolimus for the duration of antibiotic therapy
Correct answer: Contact the prescriber: erythromycin inhibits CYP3A4 and P-gp, likely causing tacrolimus toxicity
Erythromycin inhibits both CYP3A4 and P-glycoprotein, dramatically increasing tacrolimus blood levels and risk of nephrotoxicity and neurotoxicity.
Question 2: A patient on pembrolizumab (Keytruda) presents with new-onset diarrhea and colitis symptoms. Which immune-related adverse event (irAE) management is MOST appropriate?
- Continue pembrolizumab and treat symptomatically with loperamide
- Hold pembrolizumab, evaluate severity, and initiate systemic corticosteroids for grade 2 or higher (Correct answer)
- Permanently discontinue pembrolizumab for any GI symptoms
- Reduce pembrolizumab dose by 50%
Correct answer: Hold pembrolizumab, evaluate severity, and initiate systemic corticosteroids for grade 2 or higher
Immune-mediated colitis from checkpoint inhibitors requires drug hold and systemic corticosteroids for grade 2+ symptoms, with severity guiding permanent discontinuation.
Question 3: Which patient counseling point is MOST critical for a patient self-administering subcutaneous methotrexate at home for rheumatoid arthritis?
- Inject methotrexate daily at the same time each day
- Take folic acid supplementation daily to reduce mucositis and liver toxicity (Correct answer)
- Avoid all NSAIDs for 30 days after each injection
- Refrigerate methotrexate in original vials and use within 24 hours of opening
Correct answer: Take folic acid supplementation daily to reduce mucositis and liver toxicity
Daily folic acid (1 mg) or folinic acid supplementation substantially reduces methotrexate-related toxicities including mucositis and elevated transaminases.
Question 4: A patient on imatinib (Gleevec) for CML has new labs showing elevated alkaline phosphatase and ALT (5× ULN). What is the recommended MTM approach?
- Continue imatinib; these elevations are expected and not concerning
- Hold imatinib, assess for drug-induced liver injury, and notify prescriber for dose modification (Correct answer)
- Add a hepatoprotective supplement and recheck labs in 3 months
- Immediately switch to dasatinib without lab follow-up
Correct answer: Hold imatinib, assess for drug-induced liver injury, and notify prescriber for dose modification
Imatinib-associated hepatotoxicity with transaminase elevations greater than 5× ULN requires drug hold and prescriber notification for dose adjustment or alternative therapy.
Question 5: A specialty pharmacy pharmacist counseling a patient on subcutaneous injectable evolocumab (Repatha) for familial hypercholesterolemia should emphasize which storage instruction?
- Store at room temperature permanently; refrigeration is not needed
- Refrigerate at 36–46°F; if kept at room temperature, use within 30 days and do not re-refrigerate (Correct answer)
- Freeze to preserve potency and thaw before use
- Store in original packaging away from light at room temperature only
Correct answer: Refrigerate at 36–46°F; if kept at room temperature, use within 30 days and do not re-refrigerate
Evolocumab must be refrigerated but may be stored at room temperature (below 77°F) for up to 30 days; once unrefrigerated, it cannot be returned to the refrigerator.
Question 6: Which parameter requires routine monitoring when a patient is maintained on long-term nintedanib (Ofev) for idiopathic pulmonary fibrosis?
- Serum uric acid
- Liver function tests (ALT/AST) monthly for the first 3 months, then periodically thereafter (Correct answer)
- 24-hour urine creatinine
- INR monthly
Correct answer: Liver function tests (ALT/AST) monthly for the first 3 months, then periodically thereafter
Nintedanib is associated with hepatotoxicity and requires liver function monitoring monthly for the first 3 months, then periodically, with dose modification if elevated.
Question 7: A pharmacist providing MTM for a patient on oral posaconazole suspension for prophylaxis notes it is being administered without food. What is the clinical significance?
- Food has no effect on posaconazole suspension absorption
- Food, especially high-fat meals, significantly increases posaconazole suspension bioavailability; without food, plasma levels may be subtherapeutic (Correct answer)
- Posaconazole suspension must be taken on an empty stomach to prevent GI upset
- Only the delayed-release tablet requires food for optimal absorption
Correct answer: Food, especially high-fat meals, significantly increases posaconazole suspension bioavailability; without food, plasma levels may be subtherapeutic
Posaconazole oral suspension requires administration with food (preferably high-fat meal) or a nutritional supplement to achieve adequate therapeutic plasma levels.
MTM Specialty Medication Management 5
A pharmacist reviews a patient on tacrolimus post-kidney transplant who has started erythromycin.
What action is MOST appropriate?