MTM Case Study Jennifer Black Bertukan Demas Annette

MTM Case Study Jennifer Black, Bertukan Demas, & Annette Egbonim Pharm. D Candidates, 2015 Preceptor: Dr. Francis Ndemo Hampton University

Objectives Understanding the extent of drug-related problems in America Defining Pharmaceutical Care Summary of MTM The Patient Care Process Examining a Patient Case Osteoarthritis: A Closer Look Sciatica: A Closer Look Obesity: 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 drugrelated needs is held accountable for this commitment

What is MTM?

History of MTM 2003 Medicare Prescription Drug, Improvement and Modernization Act of 2003 2006 Medicare Part D 2010 Affordable Care Act

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 patientspecific information.

Care Plan The Patient Care Process Evaluation Assessment Follow-up

Case Study ~ 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 immunizations Has never had a flu shot NKDA

Condition & Medication List Indication Drug Product Dosage Regimen Start Date Condition Status GERD Nexium (40 mg) 1 Cap QD 8/19/2013 Stable Hypertension Exforge 1 T PO QD 8/19/2013 Stable Sciatica Celebrex 200 mg 2/16/14 Failure Osteoarthritis Glucosamine/ Chondroitin (500/400 mg) 1 Cap QD Recommended Partially Improved Obesity Orlistat (120 mg) 1 T PO TID CC Recommended Initial Menopause Climara (0. 025 mg/day) Apply 1 patch weekly Recommended Failure Menopause One-a-Day Menopause 1 T PO QD 8/19/2013 Failure

MTM Summary Condition Recommendation Monitoring Parameters & Follow-Up GERD Continue Nexium 40 mg 1 T PO QD Evaluate for continued need in 30 days Osteoarthritis Initiate Glucosamine/Chondroitin 500/400 mg 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 minute Initiate Orlistat 120 mg 1 Cap PO TID CC Assess for weight loss in 3 months Menopause Initiate Climara 0. 025 mg/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 cause Caused 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-Term Joint Pain & Stiffness Inability to work at all Bleeding & Infections inside the joint Bone Death Missed 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 $730 M for absenteeism and US$708 M 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-Term Missed Work Days Increased Hospitalizations Daily 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 BMI>30 Excess fat Overweight BMI>25 -29 Excess weight

Obesity ~ Epidemiology • Affects more than one-third of U. S. adults ulation Blacks of pop e g a t n e c r e P 50 40 30 20 10 0 Age 60+ Age 40 -59 Age 20 -39 Hispanics Asians Age 20 -39 Age 40 -59 Asians Age 60+ Hispanics n Whites Blacks Whites p Po u io t a l

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-Term Joint Stress Type II Diabetes Sleep Apnea Heart Disease Stroke Osteoarthritis Depression/Anxiety Cancer Death

Obesity ~ Goals of Therapy Short-Term Long-Term 5 -10% Weight Loss Prevention, Reversal, and/or Stabilization of comorbid conditions Reduction in emotional or boredomrelated eating Development of healthy eating and exercise habits Improve quality of life

Obesity ~ Monitoring Parameters Parameter Goal Monitoring Frequency BMI <30 kg/m 2 Q 3 -6 Months Waist Circumference <35 inches (female) <40 inches (male) Q 3 -6 Months Total Body Weight ~ 5 -10% Q 3 -6 Months Activity Level 150 minutes per week Q 3 -6 Months

Obesity ~ Treatment Algorithm

Obesity ~ Treatment Algorithm

References • • • http: //www. nhlbi. nih. gov/health-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/NBK 99305/ 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/Prescription. Drug. Cov. Contra/downloads/MTMFact. Sheet 2011063011 Final. pdf http: //www. cdc. gov/arthritis/basics/osteoarthritis. htm http: //www. mayoclinic. org/diseases-conditions/osteoarthritis/basics/complications/con-20014749