Applying Clinical Pharmacy to Medication Therapy Management (MTM) To Pass the NAPLEX

Applying Clinical Pharmacy to Medication Therapy Management (MTM) To Pass the NAPLEX  

This blog article highlights clinical pharmacy and how it applies to Medication Therapy Management. It also includes free NAPLEX type questions to test your learning.

Lights camera action! Once the patient enters the room or picks up the phone it's Showtime! MTM (Medication Therapy Management) is a fast pace highly interactive counseling session with the patient and the pharmacist.  MTM brings everything that you've ever learned in pharmacy to the forefront. This article will help you understand how to utilize the tools that you learned in pharmacy school. This article will also help you pass the NAPLEX by reviewing common gaps in therapy, HRMs (High-Risk Medications), and duplications in therapy to provide better patient outcomes. 

When the patient walks in/calls the first thing that the pharmacist does is collect 3 patient identifiers. Common patient identifiers include the patient's full name, date of birth, and the patient's address. Other identifiers that can be used include the patient’s member id number or in special cases the patient’s phone number. This helps you protect the patient's personal health information and helps you comply with HIPAA (Health Insurance Portability and Accountability Act of 1996) guidelines. If the phone is disconnected for any reason and the pharmacist calls the patient back or the patient calls the pharmacist, the pharmacist must reverify the patient information. If the patient is not able to verify their identity due to reasons like memory loss or frequent change in location, then the pharmacist will not be able to conduct this patient’s review. The pharmacist can always call the patient back when they may have a piece of Mail nearby or when there is a caregiver or loved one available for you to speak with, with permission from the patient. 

There are two ways that the pharmacist can conduct an MTR (Medication Therapy Review). The pharmacist can go over the list of medications with the patient or the patient can go over their list with the pharmacist. The medication review consists of going over all of the patient's medications including any additional over the counter, prescription, herbal medications, vitamins, and supplements, that the patient is taking. The pharmacist must also review all of the patient's vaccinations. Learning common vaccinations, brand and generic medication names and common gaps in therapy will not only help you provide better outcomes for your patients but will also be useful when taking the NAPLEX. Common duplications in therapy include NSAIDs (Nonsteroidal anti-inflammatory drugs) and multiple forms of Tylenol. Ibuprofen and Tylenol are very common OTC (Over the Counter) medications, patients usually do not perceive these medications as harmful and may not be able to identify different brands, generics, and combinations of these medications. Common duplications of therapy that are identified during an MTR include ibuprofen, aspirin, Motrin, naproxen, Aleve, Mobic, meloxicam, diclofenac tablets, diclofenac gel 1% (different NSAIDs). A patient may be taking multiple medications from the same drug family and/or both the brand and generic forms of medication in different strengths, but the patient may not be able to identify that the medications are the same or related, this is always a good place for a pharmacist to intervene, mention maximum daily doses like 3200mg of ibuprofen per day and mention any side effects that can happen when taking multiple NSAIDS like the increased risk of bleeding. 

Tylenol is another common medication duplication that is identified during an MTR. Tylenol comes in many forms like oral tablets, liquid suspensions, and powder. Tylenol can appear in many products like cough and cold medicine, pain medicine, and migraine medicine. Many patients do not realize acetaminophen, Tylenol, and APAP are all the same medication. During the MTR a pharmacist scans the drug list for these types of duplications. This is a great time to make an intervention and state maximum dosing like no more than 4000 milligrams of Tylenol in one day to prevent liver damage.

One of the best opportunities for a pharmacist to intervene in an MTR is when a patient has a gap in care. A gap in care is considered when a medication that is recommended by a set of guidelines for the patient’s diagnosis that the patient is not prescribed. If there is no valid reason for the patient to not take the medication like an allergy or intolerance to the medication, then it is considered a gap in therapy. For example, a pharmacist can make an intervention when a patient has asthma and is prescribed a maintenance medication like Advair and they are not on a rescue inhaler like albuterol. Another common gap in therapy is when a patient has diabetes and is prescribed an ACE/ARB, aspirin, and are not on a statin. You can let the patient know that you recommend talking to the doctor to see if this medication will be beneficial for their therapy and that this medication is recommended by the American Diabetes Associations to improve their outcomes. Diabetes is a very complex disease state and should be reviewed in great detail before taking the NAPLEX exam. 

MTRs are usually conducted with patients who are on a great deal of medication (polypharmacy), have a complex disease, state, and/or patients who are greater than 65 years old.  The BEERs list is helpful when trying to identify HRMs for patients who are greater than 65 years old. High-risk medications usually are depicted by small therapeutic thresholds for patients >65 years old. Discussing high-risk medications is another place for a pharmacist to intervene. Common HRMs include the benzodiazepine drug class. When intervening with medication in the benzodiazepine drug class like alprazolam (Xanax) a pharmacist can recommend that the patient be careful when taking the medication because they can cause an increased risk of delirium, dementia, falls and fractures, and motor vehicles accident in older adults. Another common drug class that is HRMs for people greater than 65 years old are PPI’s (Proton Pump Inhibitors) like omeprazole (Prilosec). PPI’s can increase the risk of clostridium Difficile (C. diff) as well as increase the risk of bone loss. A pharmacist can recommend that if the patient is taking a PPI and having excessive diarrhea to let the doctor know and to also get their bones checked periodically by getting a BMD test (Bone Mineral Density) scan to make sure that their bones are nice and healthy. 

The MAP (Medication Action Plan) is the next thing a pharmacist does once they have reviewed all the patient's medications, and identified any gaps in therapy, HRMs, and non-therapeutic doses. As an example, a patient who has diabetes, map points that a pharmacist may want to include is making sure that they're eating a heart-healthy diet, exercise three to five days a week for 30 minutes a day, as well as monitor their blood sugars at home and recording the reading. A common question that may appear on the NAPLEX includes goal blood sugar readings.

After a pharmacist discusses the MAP points, they review the interventions that were made earlier in the review like gaps in therapy, duplications, HRMs, and high-doses. The pharmacist also makes referrals to the doctor’s office or nurse if necessary, the pharmacist may also make a phone call or advise the patient to make a phone call right away, if it is an urgent matter. For example, if the patient told the pharmacist that they have blood in their urine or blood in their stool and the patient is taking an anticoagulant like warfarin, or if they notice that a patient has no rescue inhaler and has uncontrolled asthma the pharmacist may contact or refer the patient to the prescriber.

Now that the pharmacist has completed the medication therapy review the pharmacist must make sure to document their findings. The pharmacist needs to document the allergies, side effects, adverse reactions, vaccinations, duplications, HRMs, non-therapeutic dosing, gaps in care, and any recommendations that they have made so when the pharmacist or their peers follows-up with the patient or does their annual review they will know what to follow-up on and have some idea about the patient’s medication history. If CMS (Centers for Medicare and Medicaid Services) reviews the MTR to do an audit they will be able to identify that the medication review was conducted properly.

Here are some NAPLEX questions to test your learning from this article:

Question 1

A patient who has asthma is only taking Advair, and the pharmacist has identified a gap in therapy. Which medication should the pharmacist recommend talking to the doctor about? 

a. Amlodipine

b. Statin

c. Omeprazole

d. Albuterol inhaler

Question 2

A patient who has Type 2 Diabetes is currently taking lisinopril, metformin, and aspirin. The pharmacist has identified a gap in therapy. Which medication should the pharmacist recommend?

a. Olmesartan

b. Atorvastatin

c. Aspirin

d. Glimepiride

Question 3

A patient is on Tylenol, Norco, and ibuprofen after having knee surgery. Which of the following medications is a duplicate in therapy?

a. Tylenol-ibuprofen

b. Tylenol-Aspirin

c. Tylenol-Norco

d. Ibuprofen-Norco

Question 4

A pharmacist is conducting an MTR and identifies an HRM, which medication(s) below is an HRM for a patient greater than 65 years old?

a. Atorvastatin

b. Protonix

c. Omeprazole

d. Alprazolam

Answer to the questions

Question 1 answer: d

Question 2 answer: b

Question 3 answer: c

Question 4 answer: b,c,d

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 About the author 

Dr. Keneshia Berkley is a senior clinical pharmacist who works in MTM and clinical pharmacy. What she loves most about pharmacy is the encouragement and power that she can give back to the patient with each interaction. Dr. Berkley believes that while you may not be able to cure your patient, you can still make a direct impact in their lives by providing a smile, a kind ear, and being empathetic. A patient may not remember your name, but they will remember how you treat them. So, go out there, be great and, most importantly, show the world what pharmacists are made of!