New Pneumococcal Immunization Recommendations in Elderly Patients

Christopher Fuchs Pharm.D. Candidate 2015 Saint Louis College of Pharmacy

Christopher Fuchs
Pharm.D. Candidate 2015
Saint Louis College of Pharmacy

Pneumonia is the leading cause of infectious mortality in both children and adults. Pneumonia’s mortality ranges from 30% to 40%1, 2. With such a high mortality, one of the best options is to prevent the patient from ever getting pneumonia through immunization. As pharmacists, immunizing patients against pneumonia is a great opportunity for us to prevent a serious and life threatening infection.

Pneumonia is caused by several bacteria, viruses, and fungi. The most common bacterial pathogens include S. pneumoniae, M. pneumoniaeLegionella speciesC. pneumoniaeH. influenzae, P. aeruginosaAcinetobacter species, and methicillin-resistant Staphylococcus aureus (MRSA). S. pneumoniae is the most common pathogen and is the causative infection in 75% of pneumonia cases3. The influenza virus is the most common viral pathogen3.

There are currently two pneumonia vaccines on the market, 13-valent pneumococcal conjugate vaccine (PCV13, Brand name: Prevnar 13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23, Brand Name: Pneumovax23). PCV13 contains 13 serotypes of S. pneumoniae, specifically the 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, 23F serotypes4. PPSV23 contains 23 serotypes of S. pneumoniae, specifically the 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F and 33F5. Both vaccines are easily accessible and have been proven to prevent pneumonia infections.

The Center for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) have recently updated their guidelines on the use of PCV13 and PPSV23 in patients > 65 years old. The update is a result of the outcomes in the Community Acquired Pneumonia Immunization Trial in Adults (CAPiTA). The CAPiTA trial is a randomized, double-blind clinical trial with 84,496 participants’ age > 65 years old, which took place in the Netherlands. PCV13 was found to be 45.56% (p = <0.001) effective at preventing the first episode of vaccine-type community acquired pneumonia.

The old recommendations said to give PPSV23 to patients > 65 years old with no mention of PCV13. The new recommendations are broken down between vaccine-naïve patients and patients who have received PPSV23 already.

  • In vaccine-naïve patients > 65 years old: patients should receive one dose of PCV13 then a dose of PPSV23 six to twelve months later. The minimal time between pneumonia vaccines is 8 weeks6.
  • In patients previously vaccinated with PPSV23 > 65 years old: patients should receive one dose of PCV13 if they have not already received it. The dose of PCV13 should be given greater than or equal to one year since last PPSV23. If an additional dose of PPSV23 is indicated it should be six to twelve months from last PCV13 and greater than or equal to five years since last PPSV236.

These new recommendations will be in effect until 2018. In 2018, the ACIP will reevaluate the use of PCV13 in patients > 65 years old. The ACIP and CDC recommendations for other age groups and immunocompromised patients remain the same.

For more information about immunizations and current vaccine recommendations please take advantage of the MPA’s immunization webpage (available at https://www.morx.com/immunizations). On this page, MPA members can find information about immunization schedules, the latest immunization recommendations, specific information about the influenza vaccination, and information about National Immunization Awareness Month (NIAM).

Christopher Fuchs
Pharm.D. Candidate 2015
Saint Louis College of Pharmacy

References

  1. Nseir S, Mathieu D. Antibiotic treatment for severe community-acquired pneumonia: Beyond antimicrobial susceptibility. Crit Care Med 2012;40(8):2500–2502.
  2. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011;53(7): e25–e76.
  3. Blackford MG, Glover ML, Reed MD. Chapter 85. Lower Respiratory Tract Infections. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L.eds. Pharmacotherapy: A Pathophysiologic Approach, 9eNew York, NY: McGraw-Hill; 2014. http://accesspharmacy.mhmedical.com/content.aspx?bookid=689&Sectionid=45310531. Accessed November 17, 2014.
  4. Prenvar 13 Package Insert, Pifzer
  5. Pneumovac23 Package Insert, Merck
  6. Tomczyk S, Bennett NM, Stoecker C, et al. Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2014;63(37):822-5.

Comprehensive Diabetes Management Elective at UMKC

In the 2014 third quarter issue of the Missouri Pharmacist magazine, we printed a story about Dr. Cameron Lindsey’s Comprehensive Diabetes Management elective class at UMKC School of Pharmacy. Jordan Meyers, Pharm.D. Candidate 2015, has provided a follow up blog to the story written by Lauren Titterington, Pharm.D. Candidate 2015, about her experience in the class so we could share during American Diabetes Month.

 

Jordan Meyers, PharmD Candidate 2015, UMKC School of Pharmacy

Jordan Meyers, PharmD Candidate 2015, UMKC School of Pharmacy

To be honest, I signed up for the Comprehensive Diabetes Management elective to fulfill my required elective hours. It was one of the few electives offered that semester that fit into my schedule, but one that I had heard was very informative. I thought taking a course focused on diabetes would finally allow me to memorize the multiple classes of diabetic agents and all the important information associated with them. However, the elective went above and beyond the pharmaceutical aspect of diabetes.

One activity I enjoyed was the formation of a recipe. We were asked to prepare a food that provided carbohydrates, fat, and protein. To finish the assignment, we were to create a recipe and a food label. The preparation of my dish took much longer than I expected because of the amount of time it took to calculate the nutritional breakdown per serving. I plan to remember how time consuming the activity was when I ask patients in the future to watch what they eat and to calculate carbohydrates.

The activity that most affected me as a future pharmacist was the activity that put us in the shoes of a diabetic patient. We were assigned one of four different patients and were asked to follow their pharmaceutical plan including oral medications, injections and other non-pharmacological therapies such as foot exams and finger sticks. The patient I was assigned to did not take insulin, but was required to perform alternate site testing a couple times each day. Surprisingly, I did not have any experience with alternate site testing before the elective. On top of testing my blood sugar multiple times a day, I had to remember to take my oral medications and perform foot exams. I had to calculate carbohydrates with each meal or snack I ate and brush my teeth twice a day. By the end of the assignment, I understood how time consuming being adherent can be and what exactly pharmacists are asking their patients to do when they encourage patients to take an active part in controlling their medical condition.

A guest lecturer came into our class and spoke about the struggles she had faced and continues to face as the parent of a young girl diagnosed with diabetes. She spoke of things I had not thought of and her words strongly affected me. She helped me realize that family members of diabetic patients are affected too and might have questions that pharmacists can answer. Pharmacists should not always focus solely on the diagnosed individual.

Another activity that I enjoyed was participating in an online class led by a diabetic patient speaking to others about insulin and its benefits versus common speculations. It was wonderful to see patients encouraging other patients to control their diabetes. This activity allowed us to ask patients what they want most from the pharmacist and what we can do to be better pharmacists in the future.

Other topics we covered throughout the course included insulin pumps, pediatric and geriatric diabetic care, new and emerging diabetic treatments, and inpatient glycemic issues. All of the topics and guest lecturers taught me something new and in one way or another, changed the way I will practice as a pharmacist.

Jordan Meyers
Pharm.D. Candidate, Class of 2015
UMKC School of Pharmacy

My Experience at the Missouri Pharmacy Association

Mary Naeger, Pharm.D. Candidate 2015

Mary Naeger, Pharm.D. Candidate 2015, St. Louis College of Pharmacy

As a current P4 student at St. Louis College of Pharmacy, I have spent the past six months out of the classroom completing my Advanced Pharmacy Practice Experiences (APPE rotations). Last December, when choosing which rotations to apply for, the decision to include the Missouri Pharmacy Association (MPA) as number one on my preference list was an easy one. Completing a rotation with MPA has always been part of my plans for this year and has been an experience that I have been looking forward to for quite some time.

When I entered St. Louis College of Pharmacy as a transfer student three years ago, I quickly looked for ways to get involved with the school’s student professional organizations. My exploration led me to accept the position of student liaison with the Missouri Pharmacy Association. As the liaison, I had the opportunity to work closely with the staff at MPA to facilitate events for students on STLCOP’s campus and to coordinate student attendance at MPA’s Legislative Day and regional and state meetings. The position allowed me not only to become a student leader on campus, but also to create connections within the Missouri pharmacy community. Working with the wonderful staff at MPA has facilitated personal and professional growth by fostering leadership and nurturing relationships. Attendance at MPA events has supplemented my academic experience by exposing me to local and statewide pharmacist programs and initiatives, legislative issues and processes, and the regulation of Missouri payment and reimbursement structures, among many other things.

I have spent the past five weeks on rotation with MPA, and I have had the opportunity to take advantage of a very unique experience. The rotation’s preceptor, Dr. George Oestreich, is a consultant pharmacist in mid-Missouri and works closely with MPA. As a result of this unique structure, my rotation time was split between the MPA office and G.L.O. and Associates pharmaceutical consulting services. I have had the opportunity to attend several meetings and to learn about how consultant pharmacists work with state agencies and private organizations to provide pharmacy knowledge and expertise.

I had the opportunity to attend the MO HealthNet (Missouri Medicaid) Drug Utilization Review Board meeting in October. Attendance at this meeting allowed me to more fully understand the structure of MO HealthNet. I was able to attend a meeting of the Missouri Board of Pharmacy, which provided insight into the current activities of the Board and pertinent information for pharmacists and pharmacies. As augmentation to my classroom learning, I was given the opportunity to gain extensive knowledge about Missouri Medicaid. I had the opportunity to visit two federally qualified health centers (FQHCs) as part of a pilot program targeted at developing formal pharmacy involvement in the primary care team. I was also able to attend pilot sessions of a mid-Missouri telehealth clinic on chronic pain management and to compose a didactic presentation for use at a clinic session. It was especially interesting to me to have the opportunity to learn about these programs and to be able to experience the behind-the-scenes workings of a pilot program.

As part of my work with the rotation preceptor and his consultant service, I was able to learn about how pharmacy payment systems operate, including private third party payers, Medicare, and Medicaid. My pharmacy work experience has been singularly in inpatient hospital pharmacies, so my exposure to payment and reimbursement has been very limited in the past. Dr. George Oestreich and Dr. Jennifer Kemp-Cornelius at G.L.O. and Associates discussed the payment process with me and demonstrated several electronic tools that are available to pharmacists and health professionals, and I am grateful for the time that they have dedicated to teaching me.

MPA hosts an annual convention and trade show that varies in location yearly, as well as regional meetings called “Fall Pharmacy Nights.” These regional meetings take place in multiple areas throughout the state and allow pharmacists, students, and technicians to receive an update about the current initiatives of MPA and pertinent pharmacy happenings. I have attended Fall Pharmacy Nights in the past as St. Louis College of Pharmacy’s student liaison, and I was grateful to be given the opportunity to attend again this year. Working closely with MPA keeps me informed of the status of my profession and allows me to maintain communication with the pharmacy community.

A career as a pharmacist equates to numerous different potential career paths. As a student, I have tried to vary my experiences and gain insight into the opportunities that are available in my profession. Having the opportunity to complete this rotation has shown me that the profession is multi-faceted and that career paths are not always focused on one general area. The experience that I have gained has allowed me to understand a part of pharmacy that I was previously aware of but did not fully understand. I am grateful for the opportunity to have had exposure to consultant pharmacy and to learn about what being a consultant means.

This experience has given me a unique insight into consultant pharmacy, while providing exposure to the advocacy, education, and outreach that MPA provides for the Missouri pharmacy community. I would like to thank the staff at the Missouri Pharmacy Association and Dr. George Oestreich and Dr. Jennifer Kemp-Cornelius with G.L.O. and Associates for their time and effort hosting my rotation and teaching me. I am very grateful to have had this opportunity.

Mary Naeger, Pharm.D. candidate, 2015
St. Louis College of Pharmacy

The Gluten-Free Patient

 

Mary Naeger, Pharm.D. Candidate 2015, St. Louis College of Pharmacy

Mary Naeger, Pharm.D. Candidate 2015, St. Louis College of Pharmacy

The term “gluten-free” now adorns the shelves of grocery stores, health foods stores, and pharmacies. Gluten is an insoluble protein that is naturally found in grains such as wheat, barley, and rye and gives bread products the chewy texture.1 Avoidance of gluten has always been a reality for those with celiac disease but is now becoming a mainstream idea as many individuals discover that they have non-celiac gluten sensitivity or that they simply feel better when consuming less gluten.2 While the number of those affected by gluten intolerance or sensitivity is not accurately known, the prevalence of true celiac disease is about 1% worldwide.2, 3

Celiac disease is an autoimmune disorder that has a genetic component and an environmental component. A cell-mediated immune response results in inflammation of the small intestine and causes atrophy of the villi on the internal surface of the intestine. Atrophy of the intestinal villi disrupts absorption of nutrients and can cause weight loss, muscle wasting, chronic diarrhea, and abdominal discomfort.3 The environmental trigger for inflammation has been determined to be gluten found in wheat and grain products.4 For people living with celiac disease, avoidance of gluten is essential to controlling the inflammatory symptoms.3, 4

While it is largely known that food products made from wheat or other grains likely contain gluten, there is less widespread discussion about the presence of gluten in medications. Tablet and capsule dosage forms of medications contain the active ingredient and various excipients. Excipients, or “fillers”, are inactive ingredients that are added to the medication in order to aid in the delivery of the dosage form.5 This includes, but is not limited to, adding bulk, adjusting pH, increasing solubility, delaying absorption, flavoring, coating, coloring, sweetening, and preserving. Several excipients are derived from plant sources and have the potential to contain gluten. While gluten contamination in drugs is often trace, even a small dose of 30-50mg of gluten has been associated with symptoms in patients with celiac disease.6

Generic medications are often produced by more than one manufacturer, and the excipients in different products may or may not be the same. When evaluating medications for gluten, the most important ingredient to pay attention to is starch. While most sources of starch in medications are corn, potato, and tapioca, which are all gluten-free sources, starch can contain wheat that could potentially contaminate the medication with gluten.5 If the source of the starch is not identified (e.g. listed as “starch” or “pregelatinized starch”), further investigation is necessary. Pharmaceutical manufacturers maintain information about the ingredients that are used to manufacture their products. When contacted, they will disclose the source of the starch and will often verify if a product has been determined gluten-free (through product analysis by the manufacturer, not FDA-certified).

The four “Dex-ingredients” that may be present in medications are starch derivatives and are dextrose, dextrans, dextrates, and dextrins. Dextrose and dextrans are derived from corn and potato starches and are not sources of potential gluten contamination. Dextrates and dextrins, however, can be derived from any starch source, and the only certain way to guarantee the absence of gluten is to contact the pharmaceutical manufacturer. Fructose, cellulose, gelatin, povidone, and lactose are other common excipients that do not contain gluten and should not warrant investigation.5

Celiac patients who are highly motivated can investigate the medications that they take to determine the presence of gluten. Also, the patient’s community pharmacist can review the products available in his or her pharmacy and modify inventory, based on the patient’s needs and the financial and logistic practicality of obtaining gluten-free medications. Several online resources exist for both patients and pharmacists to investigate a medication’s ingredients.6 Clinical Pharmacology©, a subscription-based drug database, contains a product comparison report tool that lists all of the excipients in a specific drug product, based on manufacturer and National Drug Codes (NDC). The ingredient list can be reviewed to determine the potential for gluten contamination, and the manufacturer can be contacted if ingredient sources are not specified. Additionally, medication package inserts list product ingredients and are often published online by the drug manufacturer.5

Another online resource that can be helpful to patients and to pharmacists is www.glutenfreedrugs.com. This website is maintained by a clinical pharmacist at Nationwide Children’s Hospital (Columbus, OH) and contains lists of medications that are gluten free, sorted both alphabetically and by therapeutic category. The lists include over-the-counter (OTC) products and differentiate the product manufacturer for generic drugs.7 The Gluten in Medicine Identification Act of 2012 (H.R. 4972) was introduced to Congress in April 2012. The bill proposed “to amend the Federal Food, Drug, and Cosmetic Act to require the label of drugs intended for human use to contain a parenthetical statement identifying the source of any ingredient constituting or derived from a grain or starch-containing ingredient”.8 The bill, however, was not enacted, and no legislation currently exists that mandates the labeling of gluten presence in medications.7, 8 Because of this fact, the best way to determine if gluten may be a contaminant in a medication product is to investigate the ingredients of the product and to contact the manufacturer for verification of gluten-free status.

Mary Naeger, Pharm.D. Candidate, 2015
St. Louis College of Pharmacy

 

References

  1. Lee HJ, Anderson Z, Ryu D. Gluten contamination in foods labeled as “gluten free” in the United States. J Food Prot [Internet]. 2014 Oct [cited 2014 Nov 5]; 77(10):1830-1833. PMID: 25285507.
  2. Manseuto P, Seidita A, D’Alcamo A, Carrocio A. Non-celiac gluten sensitivity: Literature review. J Am Coll Nutr [Internet]. 2014 Feb [cited 2014 Nov 5]; 33(1):39-54. PMID: 24533607.
  3. Mavrinac MA, Ohannessian A, Dowling EP, Dowling PT. Why celiac disease is so easy to miss. J Fam Pract [Internet]. 2014 Sep [cited 2014 Nov 5]; 63(9):508-513. PMID: 25353024.
  4. Anderson WH, Mackay IR. Gut reactions—from celiac affection to autoimmune model. N Eng J Med [Internet]. 2014 Jul 3 [cited 2014 Nov 5]; 371(1):6-7. PMID: 24988553.
  5. Plogsted S. Medications and celiac disease—tips from a pharmacist. Pract Gastroenterol [Internet]. 2007 Jan [cited 2014 Nov 5]; 31(1):58-64. Available from http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-health/nutrition-support-team/nutrition-articles/PlogstedArticle.pdf
  6. King AR, University of Kansas Drug Information Center Experiential Rotation Students, August 2012. Gluten content of the top 200 medications: Follow-up to the influence of gluten on a patient’s medication choices. Hosp Pharm [Internet]. 2013 Oct [cited 2014 Nov 5]; 48(9):736-743. PMID: 24421547.
  7. Plogsted S. Gluten Free Drugs [Internet]. Columbus, OH; [updated 2014 May 12; cited 2014 Nov 5]. Available from http://www.glutenfreedrugs.com/
  8. Gluten in Medicine Identification Act of 2012, H.R. 4972, 112th Cong., 2d Sess. (2012).

Join in on Small Business Saturday

Join in on Small Business SaturdayThe nationally recognized Small Business Saturday (SBS) is coming up quickly on Saturday (what other day would it be!), November 29, 2014. While most people think of shopping at boutique stores, coffee houses and restaurants, why not get them thinking about your small business, the pharmacy. Since this effort is already being promoted on a national level, take advantage of it.

If you have previously participated in SBS, then keep up the good work! However, don’t stop reading, there may be some ideas you can incorporate into your current efforts. If you haven’t participated in the past, Small Business Saturday is an easy way to participate in the community, and build up recognition for your store.

To provide a bit of background on SBS, it was started to provide an opportunity to engage customers and local communities around the benefits of supporting locally owned businesses. Promotional efforts of SBS can include local chambers of commerce, convention and visitors bureaus to international companies such as American Express who founded this day in 2010.

Since this event follows one of the biggest shopping days of the year, it is to your advantage to participate while the holiday shopping mood is still in full swing. Here are several tips to help you make the most of this day for your small, locally owned business.

Local promotion: Who is promoting this effort in your community? Do they have a list that you can have your business name added to that will be displayed for community members to see? Typically, it is the chamber of commerce, convention and visitors bureau, or the downtown association that would provide marketing for this event.

Market it yourself: Spread the word through your social media channels, media advertisements, and signage and flyers throughout the store. Let people know that you will be participating in SBS and if you will have special promotions or activities for them to take advantage of. This is a great day to host your holiday open house.

Offer SBS promotions: People will still be coming off the high of Black Friday, so they will be looking for good prices and discounts on products. You don’t have to put the entire store on sale, but maybe offer a discount on a certain product line or a percentage off once a customer spends a specific dollar amount ($5 off a purchase of $60 or more).

Band together with others: If you are in a shopping plaza or have other locally owned participating businesses near you, collaborate to promote your stores and hold a special contest for participants to enter. For example, create a bingo card with all the names of the participating stores on it. Each customer takes the bingo card to the stores, receives a stamp or a sticker, and upon completion they can enter their card into a drawing to win a gift card or prize basket with products from each store.

By working together you can also increase your marketing efforts and draw in new customers to your store that might frequently visit the neighboring location.

Host a special event: Sure, participating in SBS is a special event, but make your store stand out. Something as simple as providing snacks and warm drinks to customers will provide them with happy memories and encourage them to return. If you sell local products then see if the maker of these products would come into the store to provide a demonstration, samples of the products, or even autograph the products (such as a book or CD). This will be a win-win for both locally owned businesses!

Keep the children entertained: Many families will come to SBS, so why not provide the children some entertainment while mom and dad have a chance to quietly look around. Provide a make ‘n take product for the children such as a simple Christmas ornament or card; have a local church group provide a puppet show, or convince the jolly gentleman in your store to dress up as Santa and hand out candy canes. The children will remember your store if you have something just for them, and will ask their parents to return.

No matter what you decide to do, this is a great opportunity that is already taking place, with or without you, so why not join in! For more information about Small Business Saturday and additional tips, visit the American Express Small Business Saturday website.

Sarah Luebbert
Director of Communications
Missouri Pharmacy Association