Bulletin Today
According to updated recommendations from CDC’s Advisory Committee on Immunization Practices (ACIP), patients and vaccine providers, including pharmacists, should engage in shared clinical decision making when considering pneumococcal conjugate vaccination (PCV13) in persons aged 65 years and older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and who have not previously received PCV13.
The update was announced in CDC’s Morbidity and Mortality Weekly Report (MMWR) on November 22, 2019.
Pneumococcal vaccination recommendations have undergone several changes in recent years, causing confusion for many health care providers. In 2014, ACIP recommended that older adults (ages 65 and older) receive PCV13 and pneumococcal polysaccharide vaccine (PPSV23).
In the new recommendation, ACIP said older adults should still receive a single dose of PPSV23. Shared clinical decision making between provider and patient is recommended for administration of PCV13. Considerations may include the individual patient’s risk for exposure to PCV13 serotypes and the risk for pneumococcal disease for that person as a result of underlying medical conditions. If the patient does receive the vaccination, ACIP said it should be administered first, followed by PPSV23 at least 1 year later.
Some groups of older adults are still vulnerable to pneumonia, including those who reside in areas with low childhood PCV13 uptake and could especially benefit from the PCV13 vaccination. In the report, ACIP said providers and practices caring for many patients in these groups may consider regularly offering PCV13 to their patients aged 65 years and older who have not previously received PCV13, including
- Persons residing in nursing homes or other long-term-care facilities
- Persons residing in settings with low pediatric PCV13 uptake
- Persons traveling to settings with no pediatric PCV13 program
Incidence of PCV13-type invasive pneumococcal disease and pneumonia increases with age and is higher among persons with chronic heart, lung, or liver disease; diabetes; alcoholism; and in those who smoke cigarettes or who have more than one chronic medical condition, according to the report.
In its rationale for the recommended changes, ACIP said PCV13 use in children has led to sharp declines in pneumococcal disease among adults and children.
ACIP noted that the risk for PCV13-type disease among adults aged 65 years and older is much lower than it was before the pediatric program was implemented, as a result of indirect PCV13 effects.
“The remaining risk is a function of each individual patient’s risk for exposure to PCV13 serotypes and the influence of underlying medical conditions on the patient’s risk for developing pneumococcal disease if exposure occurs,” according to the report.
PCV13 is recommended for babies younger than age 2 years and is part of the routine vaccine series.
Pharmacogenomic testing could benefit children who need PPIs
A new study from researchers at Vanderbilt University Medical Center is adding to the growing evidence that genetic variants of the CYP2C19 enzyme can affect how PPIs are metabolized. The variations may increase medication levels in the body and lead to more adverse reactions, specifically infections.
The cohort study, published in Pediatrics, looked at the common use of PPIs to treat GI disorders in children. The authors examined the DNA of 670 children aged 0 to 36 months at the time of PPI exposure.
Their findings suggest that PPI therapy is associated with higher infection rates in children with normal CYP2C19 function than in those with increased CYP2C19 function, “highlighting this adverse effect of PPI therapy and the relevance of CYP2C10 genotypes to PPI therapeutic decision making,” the study authors wrote.
“The fact that children who have been characterized as normal CYP2C19 metabolizers actually had more infection events than the fast metabolizers tells us that being exposed to these drug levels actually puts the child at risk for having an extra infection event,” said lead author Sara Van Driest, MD, PhD, assistant professor of pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt, in a press release. “We were able to highlight that these medicines do have side effects, and as clinicians we need to think very carefully about the benefits and the risks. We can consider doing a genetic test to identify if a patient is a slow, normal, or fast metabolizer.”
The CYP2C19 enzyme breaks down PPIs and works differently in each person—from slow to normal to fast, or sometimes not at all.
If there is a need to start a child on a PPI, Van Driest said a pediatrician can consider genetic testing to find out the patient’s CYP2C19 status.
Use caution when combining fracture-associated medications for older adults
Many common medications prescribed to older adults—including opioids, antidepressants, antacids, and sleep aids—can carry an increased risk of fracture. Some increase the risk of falls, others weaken bones, or they do both.
A new study published in JAMA Open Network found a strong association between the number of fracture-associated medications taken by older adults and their risk of fracture. The research showed that on average, taking any one of these drugs doubled a person’s risk, taking any two almost tripled it, and taking three or more increased fracture risk fourfold.
“With older adults consuming, on average, five medications simultaneously, we suspected that a good number of seniors are likely to use more than one of these fracture-associated drugs at a time,” said lead study author Rebecca Emeny, PhD, MPH, a research scientist at the Dartmouth Institute for Health Policy and Clinical Practice, in a press statement.
Researchers measured 21 fracture-associated drugs and the 210 pairs in combination with these drugs. Fifty-five percent of the study participants took opioids (alone or in combination with others), 40% took diuretics, and 35% took PPIs. The most hazardous combinations were found to be opioids and sedatives, opioids and diuretics, and opioids and PPIs.
When examining 2.5 million Medicare beneficiaries’ records from 2004 through 2014, the researchers looked at the number and the specific fracture-associated drugs being taken by patients. They identified hip fracture diagnostic codes from inpatient claims, used statistical analysis to measure the risk of hip fracture associated with each medication, and then compared the findings with the hip fracture risk experienced by people who took none of the fracture-associated medications. Emeny said they wanted to look at hip fractures specifically because they are among the most painful, debilitating, deadly, and costly fractures.
Taking blood pressure meds before bed may reduce CV events
A new study suggests that it might be better for patients to take their blood pressure medication before bed, not in the morning. The study, published online in the European Heart Journal and based on The Hygia Chronotherapy Trial, found that cardiovascular events were reduced by almost 50% when patients took their medication before bed.
The trial randomized almost 20,000 patients in the primary care setting and followed them for an average of 6 years. Patients in one group took their blood pressure medication before bed, while patients in another group took theirs upon waking. The group that took the medication before bed had a 45% reduction in overall cardiovascular events, which included cardiovascular death, myocardial infarction, coronary revascularization, heart failure, and stroke.
Age, gender, type 2 diabetes, chronic kidney disease, smoking, and cholesterol levels for the study group participants were all accounted for. In addition, each patient was required to wear an ambulatory blood pressure–measuring device in order to be monitored around the clock.
Researchers wrote that “one could, thus, conclude that the significant 45% reduction in CVD outcome achieved by ingestion of the entire daily dose of ≥ 1 BP-lowering medications at bedtime, compared with ingestion of all such medications upon waking […], is partly linked to better achievement of those novel therapeutic goals through improved targeting of underlying circadian rhythm-organized biological mechanisms.”
Current guidelines, as well as drug labels, do not mention or recommend a preference for morning or nighttime dosing.