MTM Case StudyJennifer Black, Bertukan
Demas, & Annette Egbonim PharmD Candidates, 2015
Preceptor: Dr. Francis NdemoHampton University
Objectives
Understanding the extent of drug-related problems in America
Defining Pharmaceutical CareSummary of MTMThe Patient Care ProcessExamining a Patient CaseOsteoarthritis: A Closer LookSciatica: A Closer LookObesity: A Closer Look
Drug-Related Problems in America
~1.5 million preventable adverse events each year
$177 billion in injury & death
Pharmaceuticals cause 40% of poison control reports in children younger than 6
2004-05: ~ 71,000 children seen in ED due to accidental medication
overdose
2011: Drug overdose was the leading cause of death
• 80% of those were unintentional
>1.4 million ED visits due to pharmaceuticals
Pharmaceutical Care
Practice in which the practitioner:
takes responsibility for a patient’s drug-
related needs
is held accountable for this commitment
What is MTM?
History of MTM
Medicare Prescription Drug, Improvement and Modernization
Act of 2003
Medicare Part D
Affordable Care Act
2003
2006
2010
Patient- vs. Prescription- Centered MTM
• Patient-centered MTM relies on the practitioner taking more care to treat the patient-specific factors involved in a case
• Prescription-centered MTM does not require the consideration of patient-specific information.
Follow-up
The Patient Care
Process
Care Plan
EvaluationAssessment
Follow-up
Case Study ~ MP
MP is a 50 year old African American female who presented to the clinic on 8/14/14 for a comprehensive medication therapy review.
Hx of GERD, Hypertension, Osteoarthritis, and Sciatica
FH significant for hypertension on her mother’s side and kidney disease on her father’s side.
Case Study ~ MP
Tobacco Use None
Alcohol Use None
Caffeine Use <2 cups per day
Exercise Walks ½ mile twice weekly
Up to date with all immunizationsHas never had a flu shotNKDA
Condition & Medication List
Indication Drug Product
Dosage Regimen Start Date Conditio
n Status
GERD Nexium (40mg) 1 Cap QD 8/19/2013 Stable
Hypertension Exforge 1 T PO QD 8/19/2013 Stable
Sciatica Celebrex 200mg 2/16/14 Failure
OsteoarthritisGlucosamine/ Chondroitin
(500/400mg)1 Cap QD Recommended Partially
Improved
Obesity Orlistat (120mg) 1 T PO TID CC Recommended Initial
Menopause Climara (0.025mg/day)
Apply 1 patch weekly Recommended Failure
Menopause One-a-Day Menopause 1 T PO QD 8/19/2013 Failure
MTM Summary
Condition
RecommendationMonitoring
Parameters & Follow-Up
GERD Continue Nexium 40mg 1 T PO QD
Evaluate for continued need in 30 days
Osteoarthritis Initiate
Glucosamine/Chondroitin 500/400mg 1 Cap PO TID
Assess pain score & mobility in 6 months
Class III Obesity
Exercise for a total of 150 minutes per week.
Goal HR>120 beats per minuteInitiate Orlistat 120mg 1 Cap PO
TID CC
Assess for weight loss in 3 months
MenopauseInitiate Climara 0.025mg/day transdermal patches. Apply
one patch each week.
Evaluate for continued need in 4 weeks
Sciatica ???? Assess pain score in 6 weeks
Osteoarthritis
Osteoarthritis ~ Definition
Aka “wear and tear arthritis”
Disease of the cartilage, joint lining, ligaments, and underlying bone.
Characterized by the breakdown of cartilage
Most often in knees, hips, and hands
Osteoarthritis ~ Differentiation
Primary (Idiopathic ) OA Secondary OA
No known causeCaused by rheumatoid arthritis,
trauma, metabolic and/or endocrine disorders
Erosion begins in the PIP and DIP hand joints Affects whole body
Seen in more elderly people Developed earlier in life
Osteoarthritis ~ Pathophysiology
Injury, excess joint loading from obesity or other causes, and/or joint instability cause damage to articular cartilage
Damaged cells cause increase in the metabolic activity of chondrocytes in an attempt to repair damage
Cartilage swells due to presence of excess constituents
Loss of balance between cartilage breakdown and re-synthesis with shift towards increasing destruction and cartilage loss
Osteoarthritis ~ Epidemiology
OA affects ~26.9 million U.S. adults 13.9% of adults aged 25-64 years
33.6% of adults aged 65 years and older
Most cases involve knees and hips
OA counts for ~70% of all arthritis-related hospitalizations
Osteoarthritis ~ Signs & Symptoms
Pain
Tenderness
Stiffness
Loss of flexibility
Grating sensation
Bone spurs
Osteoarthritis ~ Complications
Short-Term Long-TermJoint Pain & Stiffness Inability to work at all
Bleeding & Infections inside the joint Bone DeathMissed Work Days Stress Fractures
Difficulty performing tasks of daily living
Deterioration or rupture of the tendons & ligaments around the
joint
Osteoarthritis ~ Goals of Therapy
Relief of symptoms
Control Pain
Improve mortality
Improve mobility
Maintain Ideal Body Weight
Adopt healthy lifestyle
Osteoarthritis ~ Monitoring Parameters
Salicylate level Muscle Enzyme tests (CPK, aldolase) Creatinine test
Osteoarthritis ~ Treatment Guidelines
Sciatica
Sciatica ~ Definition
Pain radiating down the leg below the knee in the distribution of the sciatic nerve, suggesting nerve root compromise due to mechanical pressure or inflammation.
Sciatica is the most common symptom of lumbar radiculopathy
Sciatica ~ Pathophysiology
Compression of spinal nerve (lumbar) roots pain and neural dysfunction
Release of proinflammatory factors from the damaged disc Pain Referred leg pain
Sciatica ~ Epidemiology
Lifetime incidence varying from 13% to 40%. annual incidence of from 1% to 5%.
Men = Women Accounts for about 5% of the cases of lower
back pain 30% of patients experience persistent sciatica Recurrent episodes becomes less responsive to
treatment $730M for absenteeism and US$708M for
disablemen
Sciatica ~ Signs & Symptoms
Mild tingling, dull ache, or burning sensation Pain occurring on one side (hip, calf, or leg)
with numbness• Pain starts slowly but gets worse:
After standing or sitting At night When sneezing, coughing, or laughing When bending backward or walking more than a
few yards
Sciatica ~ Complications
Short-Term Long-TermMissed Work Days Increased HospitalizationsDaily Nagging Pain Increased Treatment Costs
Decreased Productivity
Sciatica ~ Goals of Therapy
Short-Term Long-Term
Decrease Pain Increase Quality of Life
Restore Spinal Movement Decreased Absences from Work
Improve Function Decreased Hospitalizations
Sciatica ~ Monitoring Parameters
Pain Score
Sciatica ~ Treatment/Guideline Summary
Obesity
Obesity ~ Definition
Obese OverweightBMI>30 BMI>25-29
Excess fat Excess weight
Obesity ~ Epidemiology
• Affects more than one-third of U.S. adults
01020304050
BlacksWhites
HispanicsAsians
Age 20-39Age 40-59
Age 60+
BlacksWhitesHispanicsAsiansAge 20-39Age 40-59Age 60+
Per
cen
tag
e o
f p
op
ula
tio
n
Population
Obesity ~ Pathophysiology
Energy In ≠ Energy Out
Obesity ~ Risk Factors
Obesity ~ Signs & Symptoms
BMI≥30
Waist circumference >35 inches (female) or >40 inches (male)
Clothes feeling tight and/or needing a larger size
Having extra fat around the waist
Obesity ~ Complications
Short-Term Long-TermJoint Stress Type II Diabetes
Sleep Apnea Heart DiseaseStroke
OsteoarthritisDepression/Anxiety
CancerDeath
Obesity ~ Goals of Therapy
Short-Term Long-Term
5-10% Weight Loss Prevention, Reversal, and/or Stabilization of comorbid conditions
Reduction in emotional or boredom-related eating
Development of healthy eating and exercise habits
Improve quality of life
Obesity ~ Monitoring Parameters
Parameter Goal Monitoring Frequency
BMI <30 kg/m2 Q3-6 Months
Waist Circumference
<35 inches (female)<40 inches (male) Q3-6 Months
Total Body Weight ~ 5-10% Q3-6 Months
Activity Level 150 minutes per week Q3-6 Months
Obesity ~ Treatment Algorithm
Obesity ~ Treatment Algorithm
References• http://www.nhlbi.nih.gov/health/health-topics/topics/obe/signs.html• http://www.nlm.nih.gov/medlineplus/obesity.html• http://www.cdc.gov/obesity/data/adult.html• http://www.ncbi.nlm.nih.gov/books/NBK99305/• http://www.healthquality.va.gov/guidelines/Pain/lbp/annals_2007_guideline.pdf• http://www.pharmacist.com/mtm• http://www.medscape.com/viewarticle/406802#TOC• http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html• http://www.chiropartners.com/Sciatica-Pain-Relief• https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/downloads/MTMFactSheet2011063011Final.pdf• http://www.cdc.gov/arthritis/basics/osteoarthritis.htm• http://www.mayoclinic.org/diseases-conditions/osteoarthritis/basics/complications/con-20014749
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