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

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f p

op

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tio

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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