February 2024: Case Studies

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; Janssen) 90 mg subcutaneously every 8 weeks for the past 6 months, as well as anxiety that has been treated with citalopram (Celexa; AbbVie) 20 mg orally daily for the past year. He is otherwise healthy and does not have medication allergies.

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Should the pharmacist administer the varicella vaccine?

Patients with high-level immunosuppression should not receive live vaccines such as the varicella vaccine because of the increased risk of infection, according to the Infectious Diseases Society of America. Highlevel immunosuppression occurs in 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 cells 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 been given before BB began therapy 6 months ago.

CASE 2

AE is a 70-year-old nonsmoking Hispanic woman 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 2021, and her T-score at the spine is –3.8, compared with –3.6 in 2021. Three years ago, AE started taking the bisphosphonate alendronate (Binosto; Ascend Therapeutics) 70 mg orally weekly for osteoporosis. In addition, she takes adequate doses of calcium citrate and vitamin D2. AE says she was nonadherent to bisphosphonate therapy 1 month prior to her most recent dualenergy x-ray absorptiometry scan, adding that she traveled outside the United States and forgot to bring her medication but otherwise endorses proper adherence. Her other laboratory 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; Pfizer) 5 mg orally daily. AE’s physician asks for recommendations about alternative osteoporosis medications for her.

What should the pharmacist recommend?

Prior to suggesting alternative medications, the pharmacist or prescriber should first verify AE’s adherence and administration technique, such as taking medications 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 having a very high risk of fracture, per the American Association of Clinical Endocrinology/American College of Endocrinology.³ Guidelines suggest discontinuing her oral bisphosphonate and initiating an injectable therapy, such as abaloparatide (Tymlos; Radius), romosozumab (Evenity; Amgen), teriparatide (Forteo; Eli Lilly), or zoledronic acid (Reclast; Novartis), and the duration of therapy should be determined based on drug selection. A review of AE’s drug formulary and a shared decision-making process can help identify which injectable is best. AE’s clinical status and fall risk should be assessed yearly.

References

1. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-e100. doi:10.1093/cid/cit684

2. Stelara. Prescribing information. Janssen Biotech Inc; 2022. Accessed December 7, 2023. https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/STELARA-pi.pdf

3. 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(suppl 1):1-46. doi:10.4158/GL-2020-0524SUPPL