Interactive Case Studies: November 2022 Issue

Case 1

BB is a 39-year-old man who recently moved from another state and started going to a new physician. The physician ordered the varicella vaccine, and BB is hoping it can be administered in the pharmacy. During the intake, BB says he has Crohn disease that has been treated with ustekinumab (Stelara) 90 mg subcutaneously every 8 weeks for the past 6 months, as well as anxiety that has been treated with citalopram (Celexa) 20 mg orally daily for the past year. He is otherwise healthy and does not have medication allergies.

Q: Should the pharmacist administer the varicella vaccine?

Case 2

AE is a 70-year-old Hispanic women, a nonsmoker, who has had worsening bone mineral density over the past 3 years. Her T score at the hip is –2.5 compared with –1.7 in 2019, and her T score at the spine is –3.8 compared with –3.6 in 2019. Three years ago, AE started taking alendronate 70 mg orally weekly for osteoporosis. In addition, she takes adequate doses of calcium citrate and ergocalciferol. AE said she was nonadherent to bisphosphonate therapy 1 month prior to her most recent DEXA scan, adding that she traveled outside the United States and forgot to bring her medication but otherwise follows proper adherence. Her other lab results are unremarkable for her age. AE’s height is 62 in and she weighs 56 kg. AE has hypertension for which she takes amlodipine (Norvasc) 5 mg orally daily. Her physician asks for recommendations on alternative osteoporosis medications for AE.

Q: What should the pharmacist recommend?

Answers:

Case 1:

A: Patients with high-level immunosuppression should not receive live vaccines, such as varicella, because of the increased risk of infection, according to the Infectious Diseases Society of America. High-level immunosuppression includes patients who are receiving biologic immunomodulators (eg, ustekinumab), are receiving chemotherapy, are receiving daily corticosteroid therapy equivalent to 20 mg of prednisone or greater for at least 14 days, have a primary immunodeficiency, have HIV infection with a CD4 cell count less than 200 per mm³, and/or have received a solid organ transplant within the previous 2 months.¹ Additionally, the package labeling for ustekinumab discourages administration of live vaccines after starting therapy.² Live vaccines should have ideally been given before BB began therapy 6 months ago.

Case 2:

A: Prior to suggesting alternative medications, the pharmacist and/or prescriber should first verify AE’s adherence and administration technique, such as taking it on an empty stomach, and identify whether any secondary causes of osteoporosis are present. Based on AE’s history and T score of less than –3.0, she is identified as “very high risk of fracture” per the American Association of Clinical Endocrinology/American College of Endocrinology.¹ Guidelines suggest discontinuing her oral bisphosphonate and initiating an injectable therapy, such as abaloparatide (Tymlos), romosozumab (Evenity), teriparatide (Forteo), or zoledronic acid (Reclast), and the duration of therapy will be determined based on drug selection. A review of AE’s drug formulary and shared decision-making process can help identify which injectable is best. AE’s clinical status and fall risk should be assessed yearly.

Reference

Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update. Endocr Pract. 2020;26(auppl 1):1-46. doi:10.4158/GL-2020-0524SUPPL

About the Author

Stefanie C. Nigro, PharmD, BCACP, CDCES, is an associate clinical professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.