pharmacy essential updates october 2021

Pharmacy Essential Updates October 2021

Rachel Maynard, PharmDEditorVickie Danaher, PharmDAssociate Editor Pharmacist’s Letter | Pharmacy Technician’s Letter

Copyright © Therapeutic Research Center. All rights reserved.

▪ Pharmacist's Letter / TRC Healthcare is accredited by the

Accreditation Council for Pharmacy Education (ACPE) as

a provider of continuing pharmacy education.

▪ Pharmacy Essential Updates editors disclose:

» No financial interests related to the content

» No commercial support and no advertising

» Supported entirely by subscriptions

CE Information


▪ Identify emerging trends in drug therapy and their place in

patient care practices.

▪ Describe four key considerations regarding influenza

vaccination for the 2021-2022 season.

▪ Discuss the use of various naloxone formulations for opioid

overdose.

▪ List three characteristics of finerenone for diabetic kidney

disease.

▪ Explain appropriate management of obstructive sleep apnea.

Pharmacist Objectives


▪ Identify emerging trends in drug therapy and their place

in pharmacy practice and operations.

▪ List four key considerations regarding influenza

vaccination for the 2021-2022 flu season.

▪ Recall two features of the high-dose naloxone nasal

spray for opioid overdose.

▪ Name three characteristics of finerenone for diabetic

kidney disease.

▪ Identify treatment options for obstructive sleep apnea.

Pharmacy Technician Objectives


Flu Vaccines for 2021 – 2022


It'll be all hands on deck for flu vaccines in 2021-2022...as COVID-19 continues and experts warn of a possible severe flu season.

One concern is that the low number of influenza cases last season may lessen immunity...and lead to increased severity this year.

Vaccinate now...and continue as long as flu is circulating.

Be aware, CDC now recommends against giving a flu vaccine to most patients in July and August...due to potential waning

immunity. But don't give a flu "booster" regardless of when patients got this year's vaccine.

Leverage your techs to help share the load. For instance, federal guidance now authorizes qualified techs to administer adult flu

vaccines.

Vaccines. Educate that all flu vaccines will be quadrivalent this season...with 2 updated A strains and the same 2 B strains as last

year.

Compare products in our chart, Flu Vaccines for 2021-22.

For example, explain that Fluad or Fluzone High-Dose is approved for patients 65 and older...to try to improve the immune

response.

Or if you stock FluMist, consider it an option for healthy, nonpregnant patients 2 through 49...especially if they refuse injections.

But clarify that there's no preference for one vaccine over another.

Effectiveness. Patients will hear that flu vaccines are only 40% to 60% effective...versus about 90% for mRNA COVID-19

vaccines.

But point out that these comparisons aren't apples to apples.

This is partly because each flu season is different...and we're still learning about COVID-19 vaccine effectiveness over time.

Remind patients of the big picture...COVID-19 and flu vaccines significantly reduce the risk of severe illness, hospitalization, and

death. Emphasize getting BOTH vaccinations to protect against each virus.

Co-administration. Help patients catch up on other needed immunizations (COVID-19, pneumococcal, Tdap, etc) at the same

visit.

Try to use different arms, especially with vaccines that might cause more local reactions...such as COVID-19 with Fluad or Fluzone

High-Dose.

Get our FAQ, Flu Vaccination, for answers about immunizing patients who are pregnant, feel sick, report an egg allergy, etc.

INFLUENZA

Pharmacist's Letter. October 2021, No. 371001

Emphasize the Importance of Flu Vaccination in 2021-2022



Low flu activity last season

Lower immunity?

Increased flu severity this season?


Work as a team to share the load.

Case


When should I get a flu vaccine?

▪ Recommend getting a flu vaccine by the end of October

» Takes about 2 weeks for antibodies to develop after vaccination

▪ Continue to vaccinate as long as flu is circulating

When to Vaccinate

Typical flu activity

Nov, Dec, Jan, Feb, Mar, AprOct May


▪ CDC now recommends

against giving flu vaccine to

most patients in July and Aug

» Potential waning immunity

▪ Be aware of exceptions

» Children, pregnant patients in

the 3rd trimester

▪ Don’t give a flu “booster”

When to Vaccinate


Case


Which flu vaccine should I get?

2021 – 2022 Flu Vaccines

A(H1N1)*

A (H3N2)*

B (Victoria lineage)

B (Yamagata lineage)

Quadrivalent

*Updated for 2021-2022



Recommend annual influenza vaccination for patients 6 months and older.


Clarify that there’s no preference for one flu vaccine over another.


Fluzone High-Dose

▪ 4x more antigen than standard dose

Fluad

▪ Adjuvant

Either is approved for patients 65 and older...to try to improve the immune response.


If you stock FluMist , consider it an option for healthy, NONpregnant

patients 2 through 49.

Case


I heard flu vaccines are only 40% to 60%

effective…versus about 90% for

mRNA COVID-19 vaccines.


Point out that these comparisons aren’t apples to apples.

Remind patients of the big picture... COVID-19 and flu vaccines

significantly reduce the risk of severe illness, hospitalization, and death.


Case


Can I get other

vaccines at the same

time as flu vaccine?

Yes.


Help patients catch up on other needed immunizations (COVID-19, pneumococcal, Tdap, etc) at the same visit.

Try to use different arms, especially with vaccines that might cause more

local reactions...such as COVID-19 with Fluad or Fluzone High-Dose.


▪ Watch for mix-ups

» It can be easy to mistake Fluarix...Flucelvax...FluLaval...Fluzone...

Fluzone High-Dose...etc.

▪ Keep workflow running smoothly

» Organize vaccine paperwork

» Prep supplies (gloves, cotton balls, etc)

» Monitor inventory and ensure proper storage

Practice Pearls


Higher-Dose Naloxone for Opioid Overdose


New Kloxxado (naloxone) 8 mg nasal spray will raise questions about when higher naloxone doses are needed for

opioid overdose.

Usual naloxone doses are 4 mg intranasal or 0.4 mg IM.

Kloxxado is touted as having "twice as much naloxone per spray" as Narcan nasal spray. And people are hearing higher

doses may be needed...since overdoses from "ultra-potent" fentanyl-like compounds are rising.

But there's no good evidence that Kloxxado is more effective...works quicker...or lasts longer. Point out that all

naloxone forms can be repeated every 2 to 3 minutes if needed.

Plus there are concerns that higher naloxone doses may lead to more severe withdrawal symptoms.

Focus on increasing access to naloxone...rather than which product to dispense. Tailor the choice based on patient and

payer preference.

In general, recommend a ready-to-use nasal spray for ease of administration. Narcan or Kloxxado costs about $130/2

doses...but expect more payers to cover Narcan for now.

Or consider preparing an intranasal or IM naloxone kit. These start at about $30...but require some patient assembly.

If needed, refer to local programs that offer naloxone at no charge.

Continue to discuss naloxone with each Rx for opioids or meds for opioid use disorder...this is recommended in

labeling.

Bring up naloxone as a routine and automatic part of opioid counseling, just as you'd educate about constipation.

Use clear language that avoids stigma. For example, say, "Naloxone's like a seat belt, it's there to keep you safe."

Advise keeping at least 2 doses on hand.

Instruct patients to teach family and friends about when to give naloxone...how to use it...and to call 911 and seek

follow-up.

Find more resources in our FAQ, Naloxone for Opioid Overdose, including video links to walk patients through

administration.


NALOXONE

Compare Kloxxado to Other Naloxone Products


▪ 0.4 mg IM

» Vial + syringe

▪ 4 mg

» Nasal spray (Narcan)

» Prefilled syringe + mucosal

atomization devices

▪ 8 mg

» Nasal spray (Kloxxado)

Injectable Intranasal

Naloxone Forms


▪ No good evidence that it is

more effective, works quicker,

or lasts longer

▪ Can be repeated every 2 to 3

mins if needed, like other forms

▪ Concerns it may lead to more

severe withdrawal symptoms

Naloxone 8 mg Nasal Spray



Focus on increasing access to naloxone...rather than which

product to dispense.

▪ Consider preference and cost

▪ Narcan or Kloxxado nasal spray

» Ready-to-use

» ~$130/2 doses

▪ Intranasal or IM naloxone kit

» Require some patient assembly

» Start at ~$30

Help Patients Get Naloxone

Medication pricing by Elsevier, accessed Oct 2021


▪ All states have a way for

pharmacists to provide

naloxone directly to patients

» By protocol, standing order,

etc

Expanding Access to Naloxone


▪ Clear up confusion if

patients ask for naloxone as

an “OTC”

▪ Ensure your entire team is

familiar with:

» Procedures for filling these Rxs

» Pharmacy stock of naloxone

Expanding Access


▪ Continue to discuss naloxone with each Rx for opioids or

meds for opioid use disorder

» Recommended in labeling

▪ Watch especially for higher-risk patients getting opioids

» Use of sedatives (benzos, sleep meds, alcohol, etc)

» Respiratory issues (COPD, smoking, etc)

▪ ANYONE on an opioid can be at risk

Offering Naloxone



How should naloxone be offered?

Make it a routine and automatic part of educating on opioid side effects, just as you do for constipation.


Offering Naloxone


“Naloxone’s like a seat belt, it’s there to keep

you safe.”

▪ There’s no proof naloxone

encourages opioid misuse

▪ In communities with naloxone

distribution programs, opioid

overdose deaths decrease

▪ Reinforce that naloxone can

save a life

» Overdoses can be accidental

Clear Up Misconceptions


▪ Advise keeping at least 2 doses on hand

▪ Instruct patients, caregivers, and families

» When and how to give naloxone

» Call 911, repeat a dose if needed, etc

▪ Have patients teach back

» So they know how to train others

Practice Pearls


Finerenone (Kerendia) for Diabetic Kidney Disease


KIDNEY DISEASE


Don't Jump to Kerendia for Diabetic Kidney Disease


Kerendia (finerenone) will be a new Rx for patients with chronic kidney disease (CKD) due to type 2 diabetes.

It's the first "nonsteroidal mineralocorticoid receptor antagonist"...and is approved to slow kidney disease progression and

improve CV outcomes in these patients.

Kerendia is thought to limit fibrosis and inflammation in the kidneys and heart...by blocking effects of aldosterone.

Think of spironolactone or eplerenone as working similarly. But they're steroidal...and don't have evidence of improved CKD

outcomes.

Adding once-daily Kerendia to max ACEI or ARB doses slows kidney disease progression in about 1 in 30 patients over 2.5

years...mostly due to less risk of significant eGFR decline, not kidney failure or death.

It also reduces risk of CV events in about 1 in 56 patients...likely due to reducing heart failure hospitalizations.

But think of Kerendia as a "niche" med...and weigh downsides.

It causes hyperkalemia in up to 1 in 11 patients...is not recommended in eGFR below 25 mL/min/1.73 m2...and costs about

$570/month.

Instead, continue to first emphasize optimizing BP and glucose control...and maximizing ACEI or ARB doses.

If patients with CKD due to type 2 diabetes need a metformin add-on, consider an SGLT2 inhibitor (Jardiance, etc) or possibly

a GLP-1 agonist (Victoza, etc)...especially for those at high CV risk.

Point out that these meds help protect the kidneys...improve CV outcomes...and lower glucose. Kerendia doesn't lower

glucose.

Keep in mind, SGLT2 inhibitors have more evidence for CKD than GLP-1 agonists.

Save Kerendia as a last resort to slow progression of kidney disease in patients with type 2 diabetes...when an SGLT2 inhibitor

or GLP-1 agonist isn't an option.

Don't recommend ADDING Kerendia to these meds for CKD...there's no evidence of additional benefit yet.

Advise monitoring potassium similar to an ACEI or ARB...at baseline and within 4 weeks of starting Kerendia or adjusting the

dose.

See our chart, Slowing Progression of Kidney Disease in Patients With Diabetes, for more on treatment and Kerendia's role.

▪ Type 2 diabetes is the most

common cause of chronic

kidney disease (CKD)

▪ Patients with CKD have:

» Persistent albuminuria or

» Estimated glomerular filtration

rate (eGFR) less than

60 mL/min/1.73 m2

▪ Reducing CV risk can slow

progression

Background: Diabetic Kidney Disease


High blood glucose

Inflammationfibrosis,

activation of renin-angiotensin-

aldosterone system

Kidney damage





ACE inhibitor (lisinopril, etc)

orARB (losartan, etc)

Optimizing glucose control

High blood glucose



aldosterone system

Kidney damage

▪ First “nonsteroidal

mineralocorticoid receptor

antagonist”

» Once-daily, oral med

▪ Approved to slow kidney

disease progression and

improve CV outcomes

» In patients with diabetic

kidney disease

Finerenone (Kerendia)


▪ Think of it as working similarly

to spironolactone, eplerenone

» Steroidal mineralocorticoid

receptor antagonists

» But these don’t have evidence of

improved CKD outcomes






ACE inhibitor (lisinopril, etc)

orARB (losartan, etc)

Optimizing glucose control

High blood glucose



aldosterone system

Kidney damage

Finerenone for Diabetic Kidney Disease


Slows kidney disease progression in about

1 in 30 patients over 2.5 years▪ When added to max doses of an ACEI or ARB

▪ Mostly due to less risk of significant eGFR decline, not

kidney failure or death

Reduces risk of CV events in about 1 in 56

patients▪ Likely due to reducing heart failure hospitalizations

But think of finerenone as a “niche” med...and weigh downsides.


Finerenone Downsides


Causes hyperkalemia in up to 1 in 11 patients

Not recommended in eGFR < 25 mL/min/1.73 m2

Costs about $570/month

Medication pricing by Elsevier, accessed Sep 2021

Reducing Risk in CKD Due to Type 2 Diabetes

Blood glucose control

SGLT2 inhibitor or GLP-1 agonist

Maximized ACEI or ARB doses

Blood pressure control


SGLT2 inhibitors (empagliflozin,

etc)

GLP-1 agonists (liraglutide, etc)

Finerenone

Slow CKD progression

Improve CV outcomes

Lower blood glucose



Less evidence than SGLT2

inhibitors*

*

Save finerenone as a last resort to slow progression of kidney disease in patients with type 2 diabetes...

when an SGLT2 inhibitor or GLP-1 agonist isn’t an option.



Blood glucose control

SGLT2 inhibitor or GLP-1 agonist

Maximized ACEI or ARB doses

Blood pressure control

Finerenone


▪ Advise monitoring potassium similar to an ACEI or ARB

» Baseline and within 4 weeks of starting or adjusting the dose

▪ Expect patients to start with one 10 mg tablet PO once

daily with or without food

» May titrate up to 20 mg once daily depending on potassium

levels and kidney function

» Tabs can be crushed and mixed in water or soft foods if needed

▪ Apply an “Avoid grapefruit” auxiliary label

» Grapefruit can increase finerenone blood levels

Practice Pearls: Finerenone


Managing Obstructive Sleep Apnea


SLEEP DISORDERS


Tackle Common Issues With Obstructive Sleep Apnea


About 1 in 4 adults in the U.S. have obstructive sleep apnea.

Reinforce weight loss and exercise, smoking cessation, and limiting alcohol. And be prepared to help tackle common

questions.

Continuous positive airway pressure (CPAP) is typically first-line. Advise using it at least 4 hours/night for the best

outcomes.

Explain that CPAP reduces apnea episodes, daytime sleepiness, and systolic BP...and may decrease the risk of stroke.

If the mask leaks or causes irritation, suggest getting a different mask, custom mouthpiece, or a chin strap from the

supplier.

Recommend a saline nasal spray at bedtime for a dry, stuffy nose...or switching to a CPAP machine with a heated

humidifier.

Oral appliances often work by moving the jaw forward or holding the tongue in place...to help keep the airway open

during sleep.

But generally advise saving these for mild to moderate sleep apnea...or if CPAP isn't tolerated. Appliances have less

evidence of benefit...and may need frequent replacement due to wear and tear.

Refer to a dentist for proper fitting...and discourage OTC appliances. These may change dentition, cause jaw pain, etc.

Point out that patients will need a follow-up sleep study to see if the device is helping.

Medications don't treat the underlying problem. Save modafinil, armodafinil, or Sunosi (solriamfetol) for the rare patient

with daytime sleepiness despite adhering to other sleep apnea therapies.

But advise monitoring pulse and BP...and recommend avoiding in patients with a recent CV event or multiple CV risks.

Suggest avoiding meds that may worsen sleep apnea or contribute to daytime drowsiness...benzos, first-generation

antihistamines, etc.

Review our chart, Obstructive Sleep Apnea, for more ways to improve CPAP tolerability...and pros and cons of other

treatments.

Obstructive Sleep Apnea (OSA)


Lifestyle Changes for Obstructive Sleep Apnea


Weight loss Physical activity Smoking cessation

Limiting alcohol Side sleeping Sleep hygiene

▪ Typically first-line

▪ Reduces:

» Apnea episodes

» Daytime sleepiness

» Systolic blood pressure

» Possibly risk of stroke

▪ Using at least 4 hours/night

has the best outcomes

Continuous Positive Airway Pressure (CPAP)


▪ If the mask leaks or causes

irritation, suggest:

» Different mask, custom

mouthpiece, or chin strap

▪ For a dry, stuffy nose, suggest:

» Saline nasal spray at bedtime

» CPAP with a heated humidifier

Continuous Positive Airway Pressure (CPAP)


Oral Appliances


▪ Suggest saving for mild to

moderate sleep apnea

» Or if CPAP isn’t tolerated

▪ Less evidence of benefit

▪ May need to be replaced

frequently

Oral Appliances


▪ Refer to a dentist for proper

fitting

▪ Discourage OTC appliances

» May change dentition, cause jaw

pain, etc

▪ Patients will need a follow-up

sleep study

Oral Appliances


▪ Modafinil, armodafinil,

solriamfetol (Sunosi)

» Save for the rare patient with

daytime sleepiness despite

other sleep apnea therapies

» Advise monitoring pulse and BP

» Recommend avoiding in

patients with a recent CV event

or multiple CV risks

Medications


▪ Suggest avoiding meds that

may worsen sleep apnea or

lead to daytime drowsiness

» Benzos, muscle relaxants, first-

generation antihistamines, etc

Medications


Dye Allergies


This complimentary article from Pharmacy Technician's Letter is being provided to readers of Pharmacist's

Letter, who may find its content relevant to their practice.

A recent close call will highlight your role in handling allergies to dyes or other color additives.

A child with a known red-dye allergy was getting Rx ibuprofen oral suspension. The stock bottle says the

med contains FD&C Yellow #6...initially leading pharmacy staff to believe this was the only color additive in

the product.

But the package insert also lists D&C Red #33 as an inactive ingredient. Fortunately this was caught before

the Rx was dispensed.

Help keep patients with dye allergies safe. Dyes in meds can trigger reactions...such as itching, rashes, and

even anaphylaxis.

Be familiar with common culprits, such as FD&C Yellow #5 (tartrazine)...Yellow #6...Red #40...Blue #1...and

Blue #2.

Don't assume that white meds are dye-free. Some white tabs contain FD&C Blue #1 as a brightener...and

white antibiotic powders for reconstitution may contain FD&C Red #40 to make the suspension pink.

Gather additional details if a patient reports a dye allergy. Document what the reaction was...when it

happened...and if possible, the specific dye that caused the problem.

If needed, call the manufacturer to ask if a med contains a certain dye. Don't rely solely on package inserts

or labeling...these may not have a complete or current list of inactive ingredients.

If a product must be avoided, help find alternatives...such as a different manufacturer or dosage form.

Use our algorithm, Investigating Possible Drug Allergy or Sensitivity, for help obtaining thorough allergy

histories.

ALLERGIC REACTIONS

Pharmacist’s Letter. October 2021, No. 371016

Keep Patients With Dye Allergies Safe


Med profile

Allergy: red dye

Stock bottle

FD&C Yellow #6

Package insert

D&C Red #33

Recent Case



Help keep patients with dye allergies safe.

Yellow #5 (tartrazine)

Yellow #6 Yellow #10

Red #40 Blue #1 Blue #2

Be Familiar With Common Culprits


▪ Don’t assume that white

meds are dye-free

» Some white tabs contain

FD&C Blue #1 as a brightener

» White antibiotic powders for

reconstitution may contain

FD&C Red #40

Checking for Dyes


Gathering Details


What was the reaction?

When did the reaction occur?

What was the specific dye that caused the problem?

?

?

?

▪ If needed, call the

manufacturer to ask if a med

contains a certain dye

▪ Don’t rely solely on package

inserts or labeling

» May not have complete or

current lists of inactive

ingredients

Next Steps


▪ If a product must be avoided,

help find alternatives

» Different manufacturer, dosage

form, med, etc

Next Steps


pharmacy essential updates october 2021

Documents