Case Studies (July 2019)

Case 1: MJ, a 52-year-old woman, asks the pharmacist at the local community pharmacy for the Shringrix vaccine. MJ's oncologist recommended it at her most recent visit. Upon further questioning, MJ says she has leukemia and is actively receiving chemotherapy. The pharmacist administers the Shringrix vaccine as requested.

Was the pharmacist correct to administer this vaccine even though MJ is immunocompromised?

Answer: Patients with cancer are at increased risk of developing herpes zoster. Shingrix is recommended for adults 50 years and older. It is an inactivated vaccine, not contraindicated in immunocompromised individuals. However, the Advisory Committee on Immunization Practices (ACIP) does not recommend it at this time. Per the ACIP, clinicians can administer Shringrix to patients who are anticipating immunosuppression, are taking low-dose immunosuppressive medications (<20 mg/d of prednisone or its equivalent), or have recovered from an immunocompromising illness.¹ Patients taking high-dose immunosuppressants and those with cancer were excluded from Shingrix efficacy studies, so data are lacking in these groups.² Investigators are unsure of how much of a response these patients will have, given their compromised immune systems. No evidence exists to suggest this vaccine is dangerous in patients with cancer. However, it is recommended on a case-by-case basis, after clinicians have reviewed risks and benefits.

Case 2: NT is a 37-year-old obese man with a body mass index of 55.4 kg/m² and a medical history significant for obstructive sleep apnea and vitamin D deficiency. While dropping off his prescription for weekly vitamin D 50,000 IU, he tells the pharmacist that his primary care provider (PCP) diagnosed impaired glucose intolerance in him. NT's PCP gave him a prescription for metformin, but NT prefers not to fill it at this time. NT read online that apple cider vinegar (ACV) can help people with prediabetes and prefers to try that instead because it is "natural." He wants the pharmacist's opinion on taking ACV.

Would ACV be an effective treatment for NT?

Answer: ACV is a widely available and inexpensive cooking ingredient. It has been touted as having various health benefits. In obese and overweight individuals, such as NT, the combination of ACV and a reduced-calorie diet decreases body weight, improves lipid parameters, and reduces appetite.¹ Studies investigating the glycemic benefits of ACV are limited but show promise. In a small crossover study of insulin-resistant patients, such as NT and those with type 2 diabetes (T2D), consumption of 20 g (about 4 tsp) of ACV before a carbohydrate-containing meal improved insulin sensitivity and lowered postprandial glucose, a finding that was more pronounced in those with insulin resistance.² Although NT may receive benefits from ACV, metformin is the preferred strategy, as it is known to delay the onset of T2D by 31%.³ NT should be encouraged to work on weight loss and increase his physical activity as tolerated.

Nicole Brow, PharmD, is a graduate pharmacist at CVS in Mashpee, Massachusetts.Stefanie C. Nigro, BCACP, CDE, is an assistant professor and a clinical pharmacist at Massachusetts College of Pharmacy and Health Science in Boston.

References: Case 1

• CDC. Frequently asked questions about Shingrix. cdc.gov/vaccines/vpd/shingles/hcp/shringrix/faqs.html. Updated March 26, 2018. Accessed June 13, 2019.
• Zoster (shingles). Immunization Action Coalition website. immunize.org/askexperts/experts/zos.asp. Updated May 8, 2019. Accessed June 13, 2019.

References: Case 2

• Khezri SS, Saidpour A, Hosseinzadeh N, Amiri Z. Beneficial effects of apple cider vinegar on weight management, visceral adiposity index and lipid profile in overweight or obese subjects receiving restricted calorie diet: a randomized clinical trial. Journal of Functional Foods. 2018;43:95-102.
• Johnston CS, Kim CM, Buller AJ. Vinegar improves insulin sensitivity to a high-carbohydrate meal in subjects with insulin resistance or type 2 diabetes. Diabetes Care. 2004;27:281-282.
• Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403).