Connor Walker, PharmD Candidate

Influenza is an acute respiratory infection that infects humans, birds, and other mammals on a global scale. In many cases, the classic symptoms of myalgia, sore throat, nonproductive cough, and headache are self-limiting, and resolve in 3 to 10 days. However, in the very young, the elderly, and immunocompromised individuals, the infection may last longer.

highlights this virus’ impact on older populations. Despite receiving more vaccinations than younger age groups, those aged 65 years or older account for the most influenza-related hospitalizations, complications, and deaths. The United States’ vaccination target goal for those aged 65 and older is 90%. However, the current percentage of adults aged 65 years and older who receive the vaccine equates to 65.3%, leaving approximately 35% unprotected. As part of the aging process, the body begins to experience immunosenescence, which is the gradual decline in the immune system. Unfortunately, this decline leaves the elderly more susceptible to infection by influenza.

When given the vaccine, elderly patients tend to mount a lower immune response than younger patients. With seroconversion rates ranging from 17% to 53%, this population is more at risk for infection, even when vaccinated. This creates a need for vaccines with improved seroconversion, and seroprotection in older adults.

To circumvent this poor immune response, vaccine manufacturers offer high-dose, and adjuvanted vaccines, thus provoking a stronger immune reaction. The Advisory Committee on Immunization Practices' 2017-2018 recommendation states that any formulation, standard-dose, or high-dose, trivalent or quadrivalent, unadjuvanted, or adjuvanted, is acceptable in patients aged 65 years and older. Difficulty recommending 1 product over another is due to lack of data in the geriatric population, as most available data available is drawn from younger populations. For elderly patients suffering from an egg allergy, the selection is a bit simpler, 3 FDA-approved vaccines are currently produced without eggs.

The CDC refers readers to many Toolkits available online to help expand vaccine coverage. These resources offer a variety of materials such as campaign materials, programs for improved vaccine use, language resources, and guidance for promoting the vaccine. These resources can be accessed at

https://www.cdc.gov/flu/toolkit/long-term-care/resources.htm

In addition to these online resources, this article includes a comparison chart of the current available vaccines. Many pharmacists find these charts useful to post near consultation rooms, and vaccine storage areas. Clinicians should encourage all patients, especially those aged 65 years and older, to receive the vaccine as it is proven to reduce morbidity, and mortality.

Connor Walker is a 2018 PharmD Candidate at the University of Connecticut.

Wilhelm M. Influenza in older patients: a call to action and recent updates for vaccinations.

Articles

Influenza infection in the very young, the elderly, and immunocompromised individuals may last longer. 

The Influenza Vaccine in the Aging Population

Asthma, characterized by chronic airway inflammation, currently affects more than 300 million people globally.

Common asthma-related symptoms include chest tightness, shortness of breath, wheezing, and coughing. New analyses have brought specific subtypes that share phenotypic characteristics to light. Novel therapies such as monoclonal antibodies and phenotype-guided treatments are available and clinicians are using them to help patients with severe asthma.

An article published March 2018 in the journal

touches upon some new treatment options available.

Omalizumab, a monoclonal antibody, binds and inhibits immunoglobulin E (IgE). IgE plays a role in the pathophysiology of the allergic inflammation characteristic of asthma. Omalizumab's inhibition of IgE down-regulates the immune response to gain control over the allergy-driven inflammation component.

The FDA has approved omalizumab as an add-on therapy for patients older than 6 years with severe persistent allergic asthma who remain uncontrolled with a corticosteroid and a long-acting beta-agonist (LABA). Recent studies have shown that omalizumab provided significant control over asthma symptoms, with a 30% reduction in inhaled corticoid steroid (ICS) use and a total discontinuation of systemic corticoid steroid use.

Eosinophilic inflammation often has a role in asthma as well, with interleukin-5 (IL-5) being a major cytokine responsible for eosinophil proliferation. The FDA has approved 2 monoclonal antibodies that inhibit IL-5, mepolizumab and reslizumab, for patients aged 12 years and older with severe eosinophilic asthma that is uncontrolled on corticoid steroids and a LABA. Patients treated with either mepolizumab or reslizumab had reduced asthma exacerbations and steroid use, with overall improved asthma control and quality of life.

The ability to phenotype patients suffering from asthma has identified new treatment options. However, despite these novel agents’ efficacy, it is important to consider using them only in cases of severe uncontrolled asthma. Providers should always assess the patient’s inhaler technique, medication adherence, and other modifiable risk factors before starting one of these therapies.

Connor Walker is a 2019 PharmD Candidate at the University of Connecticut.

Delimpoura V, Bonstantzoglou C, Liu N, Nenna R. Novel therapies for severe asthma in children and adults.

Providers should always assess the patientâ€™s inhaler technique, medication adherence, and other modifiable risk factors before starting one of these therapies.

Novel Treatments for Asthma

While asthma treatment options such as long acting beta-agonists and inhaled corticosteroids are effective in most patients, approximately 10% of asthma conditions will remain poorly controlled, mostly due to poor inhaler technique, poor medication adherence, and other comorbidities.

It can be difficult for providers to determine the cause of treatment failure, especially when it pertains to improper technique and medication adherence. A case study published December 2017 in the

highlights the importance of proper medication adherence in addition to 1 possible marker that clinicians can use to track adherence.

Nitric oxide is a key component in all aspects of lung function and is often implicated in asthma’s pathophysiology. The American Thoracic Society states that persistently high fractional exhaled nitric oxide (FeNO) may be caused by poor adherence to ICS therapy. These findings may indicate FeNO as a potential marker to help track ICS adherence.

The patient in this case study received a device used to monitor her adherence and inhaler technique over a 3-month period. Clinicians monitored her FeNO levels at baseline, 4, 8 and 12 weeks. Handheld FeNO devices are now commercially available, reimbursable by some insurance providers, and can be used in clinical settings.

Results of this study include a reduction of FeNO from 92 ppb at baseline to 22 ppb at 12 weeks, along with an overall decrease in airway inflammation. This demonstrates that an increase in ICS use correlates inversely with a reduction of FeNO levels.

During the 12-week period, this patient reported no asthma exacerbations and effectively weaned her maintenance steroid dose down from 40 mg to 10 mg. The patient also reported that she was able to complete a 6-km run for the first time in many years.

Providers should look at these results and remember just how imperative it is that patients are educated on the importance of technique and medication adherence. Providers should also keep in mind that these topics may need to be reinforced multiple times with patients in order to ensure the best outcomes.

Hunt E, Flynn D, MacHale E, et al. Reduction in exhaled nitric oxide tracks improved patient inhaler compliance in difficult asthma-a case study.

While asthma treatment options such as long acting beta-agonists and inhaled corticosteroids are effective in most patients, approximately 10% of asthma conditions will remain poorly controlled. 

Connor Walker, PharmD Candidate

Articles

The Influenza Vaccine in the Aging Population

Novel Treatments for Asthma

Potential New Marker May Help Clinicians Track Asthma Medication Adherence