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CCPP Interactive Case Studies
Certified Collaborative Practice Pharmacist (CCPP)
The Scenario: Managing Uncontrolled Diabetes
You are a CCPP with a Collaborative Practice Agreement (CPA) to manage patients with Type 2 Diabetes. A 58-year-old patient with established ASCVD is referred to you for an uncontrolled A1c. The patient also reports symptoms of hypoglycemia. Your role is to assess his therapy and use your authority under the CPA to optimize his regimen.
Patient Data & CPA Scope
Patient Profile & Labs
- Diagnoses: T2DM, HTN, ASCVD
- Medications: Metformin 1000mg BID, Glipizide 10mg BID, Lisinopril, Atorvastatin
- Labs: HbA1c: 8.5% (Goal < 7%)
- Complaint: Episodes of shakiness and sweating if meals are delayed.
CPA Scope of Practice (Excerpt)
- Pharmacist may initiate, adjust, or discontinue diabetes medications per protocol.
- For patients with ASCVD, an SGLT2 inhibitor or GLP-1 RA with proven benefit is recommended.
- Sulfonylureas (e.g., glipizide) carry a high risk of hypoglycemia.
Your Task
Task 1: What are the two main clinical problems with the patient's current diabetes management?
Answer:
1. Persistent Hyperglycemia: His A1c is 8.5%, indicating his current regimen is not effective. 2. Medication-Induced Hypoglycemia: His symptoms are classic signs of low blood sugar, a dangerous side effect.
Task 2: Which medication is the most likely cause of his hypoglycemic episodes?
Answer:
Glipizide. Sulfonylureas work by stimulating insulin secretion regardless of blood glucose levels, which carries a high risk of hypoglycemia. This is the problematic agent.
Task 3: According to the guidelines referenced in the CPA, what is missing from this patient's regimen?
Answer:
The patient is missing an agent with proven cardiovascular benefit. Guidelines strongly recommend an SGLT2 inhibitor or a GLP-1 receptor agonist for T2DM patients with established ASCVD.
Task 4: Acting under your CPA, what is the optimal, evidence-based change to this patient's diabetes regimen?
Answer:
The optimal plan is to discontinue the glipizide and initiate an SGLT2 inhibitor (e.g., empagliflozin). This single change resolves all identified problems: it removes the cause of hypoglycemia, adds a guideline-directed therapy for ASCVD risk reduction, and will help lower his A1c. This action can be independently ordered and documented by the pharmacist under the CPA.
The Scenario: Developing a Pharmacist-Led Anticoagulation Protocol
The primary care clinic you work at wants to improve the management of patients on warfarin. The physicians have agreed to delegate the authority for warfarin management to you, the CCPP. Your first task is to draft a clear, safe, and evidence-based protocol for the Collaborative Practice Agreement that will guide your clinical decision-making.
Clinical Context & Guidelines
Key CPA Requirements
- Must define the specific patient population.
- Must specify the functions the pharmacist is authorized to perform.
- Must include a clear, evidence-based algorithm for decision-making.
- Must specify when physician consultation is required.
CHEST Guideline Highlights
- Standard INR goal for atrial fibrillation is 2.0 to 3.0.
- For a single out-of-range INR that is not significantly elevated (e.g., < 4.5), holding doses and making small weekly dose adjustments (5-15%) is recommended.
- For a critically high INR (e.g., > 8.0) or in the presence of major bleeding, immediate physician consultation and potential reversal is required.
Your Task
Task 1: What is the primary purpose of a CPA protocol?
Answer:
The protocol serves as the "playbook" that formally defines the pharmacist's scope of practice. It provides a clear, pre-approved, evidence-based algorithm for making clinical decisions, ensuring that care is delivered in a consistent, safe, and standardized manner. It protects both the patient and the practitioners by clearly delineating the pharmacist's authority and responsibilities.
Task 2: Draft a protocol section for managing a patient with a stable INR who reports starting a new, interacting antibiotic (e.g., sulfamethoxazole/trimethoprim).
Answer:
Protocol: Management of Interacting Medications
"Upon notification that a patient has started a medication known to significantly increase the INR (e.g., SMX/TMP, metronidazole, fluconazole), the pharmacist will: 1) Empirically reduce the patient's weekly warfarin dose by 10-20%. 2) Instruct the patient to have a follow-up INR check in 3-5 days. 3) Continue to monitor the INR closely until the interacting medication is discontinued and the INR has returned to a stable therapeutic range."
Task 3: Draft a protocol section for managing a patient with a slightly elevated, asymptomatic INR of 3.8.
Answer:
Protocol: INR 3.1 - 4.5, No Bleeding
"If the patient's INR is between 3.1 and 4.5 and there are no signs of bleeding, the pharmacist will: 1) Instruct the patient to hold one dose of warfarin. 2) Reduce the total weekly warfarin dose by 10-15%. 3) Instruct the patient to return for a follow-up INR check in 1 week."
Task 4: What is a critical "escape clause" or physician notification parameter that must be included in any anticoagulation CPA protocol?
Answer:
The protocol must include clear parameters that trigger immediate physician notification. For anticoagulation, this would be: 1) Any sign of active major bleeding (e.g., black tarry stools, severe headache), regardless of the INR value. 2) A critically high INR value (e.g., INR > 8.0), even in the absence of bleeding. This ensures that the most high-risk situations are immediately escalated to the physician for co-management.
The Scenario: Managing Resistant Hypertension
A 65-year-old female with a history of heart failure and CKD is referred to your pharmacist-led hypertension clinic with persistently elevated blood pressure despite being on three antihypertensive agents. You are operating under a CPA to manage hypertension. Your task is to identify the cause of her resistant hypertension and use your prescriptive authority to optimize her regimen.
Patient Data & CPA Scope
Patient Profile & Meds
- Diagnoses: Hypertension, HFrEF, CKD Stage 3 (eGFR 45)
- Meds: Lisinopril 40mg, Amlodipine 10mg, HCTZ 25mg, Ibuprofen 800mg TID PRN for arthritis pain.
- Vitals: BP 155/95 mmHg, K+ 4.8 mEq/L
CPA Scope & Guidelines
- Pharmacist may add, stop, or adjust ACEi, ARBs, beta-blockers, CCBs, diuretics, and MRAs.
- Resistant HTN: Uncontrolled BP despite 3 agents, including a diuretic.
- Guideline: For resistant HTN, a mineralocorticoid receptor antagonist (MRA) like spironolactone is a preferred add-on agent.
- NSAIDs (e.g., ibuprofen) can significantly increase blood pressure and antagonize the effects of antihypertensives.
Your Task
Task 1: Does this patient meet the definition of resistant hypertension?
Answer:
Yes. Her blood pressure is uncontrolled (155/95) despite being on optimal or near-optimal doses of three different antihypertensive agents, one of which is a diuretic (HCTZ).
Task 2: What is the most likely medication-related cause of her resistant hypertension?
Answer:
Her high-dose, regular use of ibuprofen. NSAIDs cause sodium and water retention and interfere with the blood pressure-lowering effects of many antihypertensives, especially ACE inhibitors and diuretics. This is a common and often overlooked cause of "pseudo-resistance."
Task 3: According to guidelines, what is the preferred fourth-line agent to add for true resistant hypertension in a patient with her comorbidities?
Answer:
A mineralocorticoid receptor antagonist (MRA) such as spironolactone. It is the guideline-recommended add-on therapy for resistant hypertension and is also one of the four pillars of guideline-directed medical therapy for her heart failure.
Task 4: Acting under your CPA, what is your comprehensive, two-part plan to manage this patient?
Answer:
- Address the Root Cause: "First, I will counsel the patient on the effect of her ibuprofen on her blood pressure. I will instruct her to discontinue the ibuprofen and switch to scheduled acetaminophen for her arthritis pain. We will then re-check her BP in 2-4 weeks to see if this alone solves the problem."
- Add Guideline-Directed Therapy: "Second, because she has both resistant hypertension and HFrEF, I will use my prescriptive authority to initiate spironolactone 12.5 mg daily. This is a guideline-directed fourth-line agent for her BP and a required medication for her heart failure. I will order a follow-up potassium and creatinine level in one week to monitor for safety."
