Case Studies (May 2015)

CASE 1

A mother comes to your pharmacy counter with 2 cans of powdered infant formula that she is considering purchasing: 1 is milk protein—based and the other is a hydrolyzed formula (and significantly more expensive). She has chosen to transition her infant son to formula because of her medical conditions. She asks if the hydrolyzed formula is worth the extra money. Her son was born full-term without complications, has no known allergies, and is now 6 months of age.

What is the role of hydrolyzed formula in the nutrition of infants, and should you recommend such formula to this mother?

CASE 2

SG is a 65-year-old woman with hypertension who comes to your pharmacy regularly for her lisinopril/hydrochlorothiazide prescription. While taking care of her latest refill, you notice SG’s age and recall this qualifies her for the pneumococcal vaccination. After talking with SG, you learn she has not yet been immunized against pneumococcal infection as an adult.

As the pharmacist, should you offer the vaccination today, and with which pneumococcal vaccine?

ANSWERS

Case 1: Both milk-based and hydrolyzed formulas use cow’s milk as the protein source, although a hydrolyzed formula contains milk protein that is partially broken down. Hydrolyzed formulas are indicated in infants with a milk-protein intolerance or milk-protein allergy because the broken-down proteins are less likely to cause an adverse reaction, such as bloody stool or any combination of cutaneous, respiratory, or gastrointestinal symptoms. Although 5% to 15% of infants have adverse reactions to cow-milk protein, a minority (an estimated 2% to 7.5%) have a true milk-protein allergy. Because this infant has no known intolerance or allergy to cow-milk protein, it is not necessary for the mother to use the more expensive, hydrolyzed infant formula. As the pharmacist, you should ensure that she has selected an iron-fortified term formula since it will be the infant’s primary means of nutrition. When formula is chosen over breast milk for infant nutrition, any milk-based term formula (as opposed to preterm infant formula) that is fortified with iron is recommended for healthy, full-term infants. To help prevent the development of iron-deficiency anemia, formulas that are iron-free or fortified with low-dose iron are not recommended.

Case 2: As of August 2014, the Advisory Committee on Immunization Practices recommends a 1-time vaccination with the 13-valent pneumococcal conjugate vaccine (PCV13) for adults 65 years and older, followed by the 23-valent pneumococcal polysaccharide vaccine (PPSV23), ideally 6 to 12 months later (at minimum, 8 weeks later). Previously, PPSV23 was recommended alone in this population. This change is a result of a large randomized trial comparing PCV13 to placebo in adults 65 years or older that found significant reduction in both community-acquired pneumonia and invasive pneumococcal disease in immunized patients. PCV13 was approved in adults 50 years and older in late 2011. Therefore, if a patient 65 years or older received this vaccine prior to turning 65, he or she would not be eligible for another dose. Adults 65 years or older who previously received a dose of PPSV23, however, should receive a dose of PCV13 at least 1 year after PPSV23. Administration of PCV13 with trivalent inactivated influenza vaccine has been found to be immunogenic and safe. No data are available on the coadministration of PCV13 with other vaccines among adults. Given these current recommendations, SG is eligible to receive 1 dose of PCV13 now, followed by 1 dose of PSV23 6 to 12 months later. As SG’s pharmacist, you should offer her the vaccination today.

Read the answers

Yunes Doleh is a PharmD candidate at the University of Connecticut School of Pharmacy. Celeste Karpow is a PharmD candidate at the University of Connecticut School of Pharmacy. Dr. Sobieraj is assistant professor of pharmacy practice at the University of Connecticut School of Pharmacy. Dr. Coleman is a professor of pharmacy practice, as well as codirector and methods chief, at Hartford Hospital Evidence-Based Practice Center at the University of Connecticut School of Pharmacy.

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